Food Allergy Assessment Questionnaire
Personal Information
Full Name
Age
Email
Allergy Assessment
Do you have any known food allergies?
Yes
No
If yes, which foods are you allergic to? (List all)
What symptoms do you experience after consuming these foods?
How soon after eating do symptoms appear?
How severe are your reactions?
Mild
Moderate
Severe
Have you ever received medical treatment for your reaction?
Yes
No
Family & Medical History
Does anyone in your family have food allergies?
Yes
No
Do you have any other allergies or medical conditions?
Additional Information
Any other relevant information you'd like to share?