The Food Allergy Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.
Food Allergy Form Template UK Editable – PrintableSample
Food Allergy Form Template UK 1. Personal Information 2. Emergency Contact Information 3. Allergy Information 4. Severity of Allergies 5. Previous Reactions 6. Medication Information 7. Dietary Restrictions 8. Additional Information 9. Acknowledgment and Consent 10. Signature and Date
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WORD
Examples
[Name of the Individual]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
[Name of Emergency Contact]
[Emergency Contact Phone Number]
[Relationship to Applicant]
Please list all known food allergies and sensitivities:
1. [Allergen 1]
2. [Allergen 2]
3. [Allergen 3]
For each allergen, please indicate the severity:
1. [Allergen 1] – [Mild/Moderate/Severe]
2. [Allergen 2] – [Mild/Moderate/Severe]
3. [Allergen 3] – [Mild/Moderate/Severe]
Describe the symptoms experienced when exposed to the allergens:
[Detailed description of symptoms]
Have you ever been diagnosed with an allergy? If yes, please provide details:
[Details of medical history related to allergies]
Please describe any treatment or emergency procedures to follow in case of an allergic reaction:
[Details of treatment plan, including medications and emergency contacts]
I hereby consent to the use of this information for the purpose of managing my food allergies in accordance with the policies of [Company/Organization Name].
Signed: _____________________ Date: _______________
[Full Name]
[DOB]
[Address Line 1]
[Address Line 2]
[Contact Number]
[Name of Guardian/Parent]
[Contact Number of Guardian/Parent]
Please list any food allergies:
– [Food Item 1] – [Reaction]
– [Food Item 2] – [Reaction]
– [Food Item 3] – [Reaction]
Please specify the nature of each allergy and previous reactions:
[Detailed list of allergy responses]
Outline any specific management plans for each allergy:
[Management plan details]
What to do in case of an allergic reaction:
[Steps to take during allergic reactions, including medications to administer]
I confirm that the above information is accurate and complete to the best of my knowledge. I understand that failing to disclose allergies could result in serious health risks.
Signed: _____________________ Date: _______________
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