Fire and Earth Kitchen
This form will help us to understand your goals around eating healthfully, and let us create customized menus based on your palate and preferences. Please be as detailed as possible. If a question does not apply to you, you may leave it blank. Thank you!
Full name *
Your answer
Address *
Your answer
Phone number *
Your answer
Email *
Your answer
How would you describe your current style of eating? *
i.e. Traditional American, Eat out often, Gluten Free, Vegetarian, South East Asian, etc. Please include any diets you are on.
Your answer
Please list an example of what you might eat on an average day. *
Your answer
What types of restaurants might you normally visit when eating out?
Your answer
Are there any foods which you do not like or will not eat? *
Your answer
Do you have any favorite foods or favorite ingredients? *
Your answer
Do you have any known or suspected food allergies or sensitivities?
If so, please list them.
Your answer
Do you have any health concerns that you are hoping to address?
Your answer
What have been your greatest struggles (if any) with eating more healthfully?
i.e. time, money, commitment, will power, etc.
Your answer
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