Food Allergy Form
Personal Information
We would love to try to accommodate you to the best of our ability during dinner, drinks, and sweet treats!
Name
*
First Name
Last Name
Check the foods that have caused an allergic reaction:
Rows
Low Risk
High Risk
Peanuts
Fish/Shellfish
Eggs
Peanut or nut butter
Soy products
Dairy
Nut oils
Tree nuts (Walnuts, almonds, pecans etc.)
Sugar
Mushroom
Gluten
Sulfite
Lupins
Mustard
Other (please explain below)
Please enter any other details for us to keep in mind, including non-food related allergens:
How many times have you had a reaction?
*
Never
Once
More than once
Medications you may need access to:
What has to happen for you to react to the problem(s)?
Eating Foods
Touching Foods
Proximity
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
Submit
Should be Empty: