Food Allergy Form

The Syracuse University Food Services Food Allergy Program is designed to work with students who have food allergies. Fill out this sheet and mail or fax back to the dietitian.

Student Name:
Contact Phone:
Contact email:
Dining Center:
I am allergic/intolerant to:
Fish: Which fish?

How severe-ingest/inhale/on contact
Shellfish: Which shellfish?

How severe-ingest/inhale/on contact
Tree Nuts: Which nuts?

How severe-ingest/inhale/on contact
Peanuts: How severe-ingest/inhale/on contact
Milk: How severe-ingest/inhale/on contact

Is it an allergy or an intolerance?
Eggs: How severe-ingest/inhale/on contact
Wheat: Do you have a Wheat Allergy or Celiac Disease?
Soy: How severe-ingest/inhale/on contact
Do you carry on Epi Pen?
yes no		 Do you wear a Medic Alert bracelet? www.medicalert.com
yes no