Food Allergy Screening Questionnaire
Full Name
Date of Birth
Email
1. Have you ever experienced any allergic reaction after eating certain foods?
Yes
No
2. List any foods you suspect cause a reaction:
3. What symptoms did you experience? (Check all that apply)
Skin rash/hives
Swelling (lips, face, throat, etc.)
Difficulty breathing
Nausea/vomiting/diarrhea
Other
If "Other", please specify:
4. How soon after eating the food did the symptoms appear?
Immediately
Within minutes
Within an hour
Other
If "Other", please specify:
5. Have you ever needed emergency medical attention due to a food reaction?
Yes
No
If yes, please describe what happened:
6. Do you have a diagnosed food allergy?
Yes
No
If yes, by whom?
7. Please provide any additional information relevant to your food allergies: