Food Allergies, Intolerances, and Restrictions

Full Name *

Do you have any food allergies, intolerances, or restrictions?YesNo

Please select any food allergies you have (check ALL that apply):DairyFishSoyShellfishEggsSesamePeanutsCornTree nutsWheat (Please do not check this for celiac disease or gluten sensitivity—only select this if you have a wheat allergy)Other

If other, please list your allergies here:

Please select any food intolerances you have (check ALL that apply):Gluten (celiac disease or non-celiac gluten sensitivity—includes wheat, barley, oats, rye)LactoseFructoseSulfitesHistaminesNitritesFructansTyramineGalactansFava BeansMSGSalicylatesPolyolsCitric acidNightshadesOther

If other, please list your intolerances here:

Please list any specific ingredients you're allergic to:

Please list other special diet needs or restrictions (e.g. Diabetes, IBS, etc.):

What are the preferred food substitutions, if any? (e.g. gluten free bread, soy milk, etc.)

What are your allergic responses?

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