Food Sensitivity – Autism Odyssey

Be Kind Form

Your Name*

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Food Sensitivity Form for

First Last

I have SEVERE reactions to the following foods:

SEVERE reactions to Other Foods

Please do the following if I ingest one of these foods:

I have MODERATE reactions to the following foods:

MODERATE reactions to Other Foods

Please do the following if I ingest one of these foods:

I have MILD reactions to the following foods:

MILD reactions to Other Foods

Please do the following if I ingest one of these foods:

These are my favorite foods:

These are my favorite textures:

These are my favorite beverages:

How to encourage me to eat healthy foods:

Favorite restaurants and what to order:

Snack foods I like:

Emergency Contact

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