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Food Allergy Questionnaire

Records a patient's food allergies: trigger foods, symptoms, reaction severity and precautions such as carrying an epinephrine auto-injector. A clear tool for medical practices, schools and camps.

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Full Name

First Name

Last Name

Date of Birth

Parent / Guardian Name

First Name

Last Name

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

Do you have any diagnosed food allergies?

Yes No Not sure

Which food(s) are you allergic to?

Peanuts Tree nuts Milk and dairy Eggs Wheat or gluten Soy Fish Shellfish

What symptoms do you experience during an allergic reaction?

Hives or rash Swelling Breathing difficulty Vomiting Diarrhea Dizziness Anaphylaxis

When was the allergy first identified?

In infancy In childhood In adolescence In adulthood

How severe are your reactions usually?

Mild Moderate Severe Life-threatening

Have you ever had an anaphylactic reaction?

Yes No Not sure

Do you carry an epinephrine auto-injector (EpiPen or similar)?

Yes No Not sure

Have you been prescribed any allergy medications?

Yes No Not sure

Do family members/caregivers know how to respond to a reaction?

Yes No Not sure

Do you read ingredient labels before eating packaged foods?

Always Usually Sometimes Never

Are you concerned about cross-contact / cross-contamination?

Yes No Not sure

Do you avoid eating at certain restaurants or events because of your allergy?

Yes No Not sure

Please describe any other allergies or medical conditions

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