Allergy Information Provider: _____ Student ______ Parent
_____ Other Provider (Specify)
What is the allergy(ies)? ________________________________________________
At what age did allergy diagnosis occur? ________ (Age in years) Current Age ______ (Age in Years)
Is an EpiPen required for the allergy(ies)? ____Yes ____No If yes, specify EpiPen allergy(ies) ____________________________________________________
Does anyone else in the family have allergies?
____Yes ____No If Yes, list Who ______________________ What allergies _________________________________
1. Apart from a cure for your allergy, what would you most like to see happen in the world of food allergies?
_____ More Services _____ Tax Credits for Expenses
______ More Research _____ Other: Identify ___________________________________________________________
2. After more than 25 years of “unheard of” food allergies and the proliferation of severe food allergies, do you think the work on a cure has been sufficient? ____Yes ____No How would you rate it on a scale of 1 -10
____ (1 is least favorable, 10 is most favorable)
3. Have you ever had to excuse yourself from an event or activity as a result of your food allergy(ies)? ____ Yes
No_____ If Yes, _____Sometimes _____Often List Top Three
4. What are the challenges of living with food allergies? Identify the top three.
5. Are you satisfied with current food ingredient labeling? ____Yes ____No
6. Should ingredients that are unknown or difficult to pronounce be allowed on food ingredient listing? ____Yes ____No
7. Are you satisfied with schools providing allergy friendly services? ____Yes ____No
If No, what could be done to make it better? List top three. 1____________________________________________________________
8. Are you satisfied with community and recreational groups providing allergy friendly services? ____Yes ____No
If No, what could be done to make it better? List top three.
9. Are you satisfied with restaurants providing allergy friendly services? ____Yes ____No
If No, what could be done to make it better? List top three. 1._____________________________________________________________
10. Do you think that government is taking adequate action to provide allergy friendly services? ____Yes ____No
If no, what could be done to make it better. ________________________________________________________________
11. Do you support emerging treatments for reducing and eliminating food allergies? ____Yes ____No
If yes, have you used any of these treatments & outcome? Specify type of treatments used (includes immunology, gradual introduction of allergen, acupuncture etc.).
12. Do you think that government funding should be made available for those living with severe food allergies, (includes related
asthma and environmental) reflecting the expenses required for special diets, products and prescription medicine?