Food Allergy Form
Personal Informations
Name
*
First Name
Last Name
If we will need to contact with you for further questions about your alergies , how can we contact with you?
*
Phone
Mail
Phone Number
-
Area Code
Phone Number
Email
example@example.com
History and Current Status
Check the foods that have caused an allergic reaction:
Rows
Low Risk
High Risk
Peanuts
1
2
Fish/Shellfish
3
4
Eggs
5
6
Peanut or nut butter
7
8
Soy products
9
10
Milk
11
12
Nut oils
13
14
Tree nuts (Walnuts, almonds, pecans etc.)
15
16
Sugar
17
18
Mushroom
19
20
Gluten
21
22
Sulfite
23
24
Lupins
25
26
Mustard
27
28
Other
29
30
Please enter all of the other foods that have caused an allergic reaction
How many times have you had a reaction?
*
Never
Once
More than once
If more than once, please explain ;
When was the last reaction?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What has to happen for you to react to the problem food(s)?
Eating Foods
Touching Foods
Smelling Foods
Other
How quickly do the signs and symptoms appear after exposure to the foods?
Seconds
Minutes
Hours
Days
Other
Additional notes you want to add
Signature
Submit
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