Pre-Stay Questionnaire Regarding Food Allergies

This questionnaire is to inquire about food allergies and does not apply to food preferences.
If you have allergies to multiple ingredients, we may not be able to accommodate your requirements depending on the level of severity.
We may need to follow up with you, so please make sure to provide your contact information.

Due to the operational constraints of our ryokan (traditional inn), it may be challenging for us to fully accommodate your requirements, and therefore,
we cannot assume responsibility for your food allergies. For your safety, if you have severe allergies, please consult with your physician in advance.

* If there are multiple guests with allergies within the same group, please fill out one form for each guest.

Name
Accommodation representative name (day trip representative name)
Tel
Email address
Email address (for confirmation)
Gender
Arrival date

*If you are using it for a day trip, please enter the date of use.
Number of nights
（1）Are you currently diagnosed with food allergies by a physician and receiving treatment?
（2-1）(1)Please enter the first food you are allergic to. (* If you are allergic to multiple foods, please make a separate entry for each one.)
Ex. 1: Beef allergy Ex. 2: Shellfish allergy (Shrimp, crab, oysters, clams, and other mollusks and crustaceans)
（2-2）(1)Level of sensitivity (Tick the types of foods that cause allergic reactions)
（2-1）(2)Please enter the second food you are allergic to.
Peanuts and tree nuts (Allergic to all tree nuts and peanuts except for almonds and cashew nuts)
（2-2）(2)Level of sensitivity (Tick the types of foods that cause allergic reactions)
（2-3）If you are allergic to three or more food items, please specify below.
③Have you had an anaphylactic reaction in the past?
④Are you prescribed with an epinephrine?
⑤If you have additional concerns, please provide detailed information.

This questionnaire serves as a reference to ensure food safety for guests with food allergies who will be staying and dining at our establishment. This document will not be utilized for any other purposes.

Additionally, this questionnaire will be stored and disposed of under our responsibility with consideration for your personal information.

If you agree to the above statement regarding the handling of personal information, please provide your signature and submit this form.

I agree to the handling of personal information.