Dietary Needs Form
We are committed to working with students to meet their individual dietary needs.So we can better serve you, please fill out this form and submit it online directly to the Dietitian.
Full Name:
*
First Name
Last Name
Your Email:
*
example@oswego.edu
Your Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
ID Number:
*
Primary Dining Center:
*
Please Select
Cooper
Lakerside
Pathfinder
Residence Hall:
*
Please Select
Cayuga Hall
Seneca Hall
Oneida Hall
Onondaga Hall
Hart Hall
Funnelle Hall
Waterbury Hall
Riggs Hall
Scales Hall
The Village
Class Status:
*
Please Select
Freshman
Sophomore
Junior
Senior
Graduate
Dietary Restrictions (check all that apply)
*
Celiac Disease - Diagnosed Only
Egg Allergy
Fish Allergy
Lactose Intolerance
Milk Allergy
Tree Nut Allergy
Vegetarian
Wheat Allergy
Gluten Allergy
Vegan Diet
Peanut Allergy
Shellfish Allergy
Soy Allergy
Other Allergy
Other Intolerance
Other Special Diet
If you have an allergy...
When was the last time you were seen by an allergist?
Do you carry an antihistamine drug such as Benadryl with you?
Please Select
Yes
No
Not Applicable
Do you have a prescribed epinephrine auto injector?
Please Select
Yes
No
Not Applicable
Have you previously met with a Registered Dietitian?
Please Select
Yes
No
Not Applicable
Food Allergy/Intolerance:
Medically Prescribed Diet:
List the foods you typically eat...
Foods I typically eat for Breakfast:
Foods I typically eat for Lunch/Brunch:
Foods I typically eat for Dinner:
Comments:
Submit
Should be Empty: