ITALY TRIP Questionnaire I: Health, Allergies, etc. - (copy)

ANDIAMO I : Sage SAS
Name: 


  1. Give the legal spelling of your name: LAST, FIRST MIDDLE


  1. Here is the email address that I check most regularly:


  1. I PREFER/MY SON/DAUGHTER PREFERS VEGETARIAN FOOD:
    Yes
    No


  1. I PREFER/MY SON/DAUGHTER PREFERS A VEGAN DIET:
    Yes
    No


  1. I AM ALLERGIC TO SHELLFISH:
    Yes
    No


  1. If you are ALLERGIC to SHELLFISH, which sort of shellfish cause the allergic reaction?


  1. I HAVE OTHER FOOD ALLERGIES:
    Yes
    No


  1. If you do have other FOOD ALLERGIES, please state them here:


  1. If you have ANY allergies, DO YOU CARRY AN EPI-PEN?
    Yes
    No


  1. Select any that apply to you:
    I burn easily in sun light
    I do NOT swim (OR) do NOT swim WELL
    I have VERY LITTLE OR NO bike experience
    I suffer from vertigo


  1. If you have a medical condition that you wish to keep in confidence, please approach Ms. Fu, Ms. Howe or Mr. Novotny at a time and place comfortable for you. All medications must be reported to us before we leave on the trip. You may leave a comment here if you wish.





Lance Novotny
ID