卵 (Egg)

乳 (Milk)

小麦 (Wheat)

そば (Buckwheat)

落花生 (Peanut)

くるみ (Walnut)

えび (Shrimp)

かに (Crab)

その他 [下記の欄に記入ください] (Other, fill below):

①軽度（素材そのものでなければ大丈夫。加工品等）Mild (Okay as long as it is not the ingredient itself; processed foods are acceptable.)

②中等症（つなぎ程度であれば大丈夫）Moderate (Okay if only a small amount is used as a binder or ingredient.)

③重症（食材すべて取り除かなければいけない Severe (The ingredient must be completely removed from all food.)

④最重症（調理器具等も全て分け、別調理しなければならない）Most Severe (Separate utensils and equipment must be used, and the food must be prepared separately to avoid cross-contamination.)

①軽傷（過去には特に変化ない）Minor injuries (no particular changes in the past)

②中等症（過去に軽い蕁麻疹等が出る）Moderate symptoms (past mild hives, etc.)

③重症（過去に呼吸が苦しくなったことがある）Severe (has experienced difficulty breathing in the past)

④最重症（過去に救急搬送されたことがある）Most severe case (has been transported to the hospital by ambulance in the past)