Date of Event
CeliacDiabeticGluten FreeNo PorkNo Red MeatVeganVegetarianOtherNot Applicable
How do you manage the diabetes? (i.e. Are you on insulin? Do you take Metformin? Are you diet controlled? What are your dietary requirements? etc.)
If "Other" please specify:
Apples / PearsBananasBerriesNo PorkEggsFishKiwiPitted FruitPeanutsShellfishTree NutsDairy / Lactose IntolerantOtherNot Applicable
Take medication and eat/drink dairy products.Do not eat/drink dairy products.Generally avoid dairy products, but occasionally takes medication and indulges.
ModerateSevereCauses AnaphylaxisNot Applicable