We are committed to working with students to meet their individual dietary needs.

So we can better serve you, please fill out this form and submit it online directly to the Dietitian.

Student Name:

ID Number:

Class Status:

Residence Hall:

Primary Dining Center:

Contact Phone Number:

Contact Email:

Dietary Restrictions (check all that aply)

Celiac Disease - Diagnosed Only
Egg Allergy
Fish Allergy, Kinds:
Lactose Intolerance
Milk Allergy
Peanut Allergy
Shellfish Allergy, Kinds:
Soy Allergy

Tree Nut Allergy, Kinds
Vegetarian, Type
Wheat Allergy
Gluten Allergy
Vegan Diet
Other Allergy:
Other Intolerance:
Other Special Diet:

If you have an allergy....

  • When was the alst time you were seen by an allergist?
  • Do you carry an antihistamine drug such as Benedryl with you?
  • Do you have a prescribed epinephrine autoinjector? If so, do you carry it with you?

List the foods you typically eat for:

Breakfast:

Lunch/Dinner:

Have you previously met with a Registered Dietitian?  
Food Allergy/Intolerance:
Medically Prescribed Diet:
Comments:
 

 

 

If you have any questions please contact Sarah Formoza at 315-312-3284 or email at sarah.fomoza@oswego.edu.