Food Choice Questionnaire
Date *
Your answer
Name *
Your answer
Address *
Your answer
Are you in a gated community or specificly named subdivision or development?
If so, what is the name?
Your answer
home phone *
Your answer
Mobile phone *
Your answer
email address *
Your answer
What is your primary objective for hiring a personal chef? Please explain. *
ex., health issues, weight loss, convenience, save money, athletic performance,etc...
Your answer
How many people are in your household? *
Will I be cooking for children?
Your answer
Do you have any pets? *
Are they indoor? outdoor?
Your answer
Does any family member have food allergies/intolerances?
Which family member/s, what are they?
Your answer
Are there any dietary restitrictions/ concerns in the family.
Which family member and is there an associated medical condition?
Your answer
Are you on a weight loss program?
Which one? Please give a brief explanation of the program.
Your answer
Are you interested in following a low carbohydrate diet?
Check all that apply
Is anyone in the household an athlete or avid fitness practitioner?
Please explain.
Your answer
What is your hot spicy food scale? *
Are there any herbs or spices I should not use in your meals? *
please list
Your answer
Do you like spicy foods that are not "hot" in nature *
These spices might include cumin, corriander, curry, paprika, etc...
May I cook with wine or liquor? *
What vegetables do you like?
Start with your favorites and what you typically eat.
Your answer
What vegetables do you dislike?
Your answer
What fruits do you like?
Begin with your favorites and what you typically eat, including dried fruits.
Your answer
What fruits do you dislike?
Your answer
Are you open to vegetables and fruits that are not otherwise listed on your 'like" or "dislike" list? *
If you can, be specific about what you're willing to try.
Your answer
What restaurants do you frequent?
Your answer
What types of cuisine do you like? *
For example: Classic American, Mexican, Italian, French, Thai.
Your answer
How important are organic ingredients? *
Where do you do your grocery shopping?
Your answer
Do you grow herbs at your home?
What types?
Your answer
Do you have a vegetable garden?
What do you grow?
Your answer
Which of these proteins do you eat on a weekly basis? *
Choose all that apply.
Required
If you like seafood, what types do you typically eat? *
For example; grouper, salmon, shrimp, oysters, etc...
Your answer
When eating poultry which do you perfer? *
Do you or your family like chicken/meat that's on the bone? *
Your answer
What are your family's favorite dishes?
Do you have recipes you would like me to use?
Your answer
Do you eat salads?
What type of salad greens do you prefer?
Your answer
Are you or anyone in your household vegetarian/vegan?
Is it the whole family or certain members? Please explain.
Your answer
What type of storage containers do you prefer? *
Do you plan to provide your own or would you like me to purchase them?
How would you like your entrees packaged?
Which appliances will you use to heat your meals?
Does your oven maintain an accurate temperature?
What kind of freezer is available to store your food?
Do you have extra refrigeration?
Where is your breaker box located?
Your answer
Do you have security system that requires a pass code to enter your home?
Use this space to add any other information you would like to share about your family's health, eating habits and requirements that you would like me to know.
Your answer
Is there a specific person or source that referred you to Mindful Meals?
Your answer
Would you like recieve the Mindful Meals newsletter via email?
Please provide your preferred email address.
Your answer
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