SAMPLE TO FILL IN（英語）② 食物アレルギーに関するアンケート

DATA DE
PREENCHIMENTOSURVEY ABOUT FOOD ALLERGIC

School name○ grade ○ class

HAMAMATSUSHIRITSU ○○SHOGAKKO
Períod of stay:from OO月

OO日（） ～toOO月

OO日（①Is the child allergic to any food?
⇒はいYES②Please circle below (○) the allergenic food.

・TEL p/ contact:）○○ ○○Student name

いいえNO/○○ ○○Guardian/resp

OOO-OOOO-OOOO/.
㊞

Possible contact hour:

If the answer is YES, continue to number ②. If the answer is NO, the survey is finish..

＊Service needed（＊１）つなぎは大丈夫 No problem if mixed with other ingredients in small amount ... Remove the allergic food in visible format. (Example: in case of egg allergy, the child does not eat omelet
If allergic to milk does not drink milk / if allergic to shrimp does not eat fried shrimp).

（＊２）完全除去 Remove completely ... Remove seasonings and foods containing egg white, lactose, wheat flour, meat and fish.
（＊３）加熱すれば大丈夫 If the food is cooked no problem.
If "YES", circle the table according to the corresponding

Allergic food not listed should be
written in "OTHERS".".

allergic food and write about the allergic food.
※Please understand, thist is not about food the student likes or dislikes. This is an allergy research.
Please complete considering that exercise-induced allergy may occur★We can not totally remove the allergic substance.(Therefore, depending on the symptoms we will ask the child to bring hir/her own food.)

アレルギー食物 ALLERGIC INGREDIENTTOMATO

Cashew Nuts

ごまカナ
シッツューSesameバナナ

BANANA

くるみオレンジOrangeキウィ

Nuts

その他 OTHERSKIWIやまいもINHAME
WILDももまつたけMushroom
MATSUTAKE

いくらPeach

あわびSalmon

いかMOLUSCOABALONEりん
ごSquid

さばAppleFISH
MACKEREL

さ
けSALMON

大豆ゼラチンGELATINE

鶏肉SOY

豚肉

Chicken

牛肉

Pork

かに

Beef

えび

特定原材料に準ずるもの OTHER FOOD

Crab

そば

Shrimp

落花生

weat

小麦

Peanut

乳Weat

卵Milk

SERVICEREQUIRED

Egg

特定原材料 MAIN FOOD

つなぎは大丈夫（＊１）
No problem if mixed in smallquantity
完全除去（＊２）○Remove completely
加熱すれば大丈夫（＊３）

If cooked, no problem.

特記事項（症状等）
What you want toreport (eg,symptoms, etc.)○○○

具体的な食品名等を記入してください。Write allergy foods.

EGG (CAN NOT EAT MAYONNAISE SALAD)MILK (CAN NOT TAKE MILK, ONLY HOT MILK

③Would you klike to replace the menu? ⇒はいYES・

Write about the food the child isallergic to.

いいえNO

If "YES", the company MC Food
Service may get in contact by phone.

④Would you like to talk to the person in charge? ⇒ は い YES い い え NO

※以下は当センターで記入します。The space below will be filled by the establishment.

アレルギー対応メニュー

１日目 夕食 Diner for 1st dayAllergySupportmenu

5/16
Pasta salad (replaced by)⇒ Chinese Salad withHarusame
Sliced tomato⇒Brocoli namuru

I agree with the allergy menu written above.

２日目 朝食 2nd day breackfast

5/17
Potato salad (replaced with)⇒Fried potato

２日目 昼食 2nd day lunch

5/17
Creamy Sesame Sauce⇒Red onion sauce

２日目 夕食 2nd day diner

5/17
Gobo salad (strong root) withcorn⇒Brocoli with okaka (grated dryfish)

３日目 朝食 3rd day breacfast

5/18
Spaghetti with bacon⇒Suggested with tuna
Omelet (with ketchupi)⇒Fried bread

３日目 昼食3rd day lunch

5/18
No change(If you do not need
Change will be written"No change"

The allergy care menu will beWritten 「○○ ⇒ □□」 and will be returned to the .

If you agree with the "allergy care menu",
please sign and stamp.

Guardian or responsible ○○○○※The above information will only be used for meal subject in our establishment. After use it will be cut and burned.
※Deadline to answer: ⇒ We need to send to MC Food Service up to 21 days in advance.
19Kabushikigaisha MC Food Service〒435-0045 Shizuoka ken Hamamatsu-shi Naka-ku Hosojimacho 10-4
Responsible： IKEDA㊞ TEL: 053-411-6133 FAX: 053-411-6213【Hamamatsu-shi Kawana Yagai Katsudo Center, refectory】
TEL(FAX) refectory: 053-544-0432
Responsible: TEGURI