Harding Dietary Restriction Survey

Harding Dietary Restriction Survey

First Name

Last Name

Form Date Field

Contact Phone Number

Contact E-mail

What is Your Campus Affiliation?

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Anticipated Date You Will First Dine On Campus

Do You Have Any Food Allergies?

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Which Specific Tree Nuts (or All Tree Nuts)?

Which Specific Fish (or All Fish)?

Which Specific Shellfish (or All Shellfish)?

Please Identify Any Oher Food Allergies Below:

What Types of Contact Will Cause a Reaction?

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Do You Have an Epineprine Autoinjector?

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Intolerances, Sensitivities, Religious, Other

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Please Identify Any Other Dietary Needs:

Which Places On-Campus Do You Eat or Plan to Eat?

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Do You Understand the Food Allergy or Medical Condition?

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Are There Any Other Questions or Concerns We Can Answer For You?