Dietary & Medical Information Questionnaire

In order that special dietary and medical conditions can be dealt with when students are on field courses and undertaking classwork, it is essential that the following form be completed. Please feel free to discuss any queries in confidence.

ANSWER ALL QUESTIONS, EVEN IF THE ANSWER IS ‘NO’.

Firstname:
(as on passport) / Lastname: / Sex : / M / F
Degree Pathway : / Student number : / Date of birth:
NHS number:

Special dietary requirements: - Delete as appropriate

Are you vegetarian? / YES / NO / If the answer to ANY of these questions is YES, please give details of what you are UNABLE to eat:
Are you vegan? / YES / NO
Are you gluten-intolerant (coeliac)? / YES / NO
Are you lactose intolerant? / YES / NO
Do you have a nut allergy? / YES / NO
Do you have any other known food allergies? / YES / NO
Do you have any religious / cultural dietary restrictions? / YES / NO

Medical conditions : - Delete as appropriate

Are you affected by any of the following conditions?

Possible effect on fieldwork / Possible effect on class work
Epilepsy / YES / NO
Diabetes / YES / NO
Asthma / YES / NO
Vertigo / YES / NO
Others
(please
specify)

Dietary & Medical Information Questionnaire

Passport details:

Nationality:
(as on passport)
Passport number:
Passport expiry date:
Passport Issue Date :

Participants in residential fieldwork represent the university in the host communities and are expected to behave sensibly and respectfully at all times. By signing this form you are agreeing to uphold the University’s good reputation, to participate actively in the fieldwork activities, and to follow staff guidance especially in regard of Health & Safety issues. You also confirm your understanding that unacceptable behaviour (including any such resulting from abuse of alcohol) will result in exclusion from the fieldwork and repatriation at your own expense.

I understand that withholding any relevant dietary or medical information may result in jeopardising my health and/or safety in an emergency situation.

I understand that the information given in this form will be kept securely and confidentially, and processed in accordance with the University’s Data Protection Policy. I give my consent for this information to be used by staff of the School in the context of my academic studies, including fieldwork.

I have read and accept the above statement:

Signed: / Print Name: / Date: