Food Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Food Questionnaire

INTRODUCTION

Your First Name

Your Last Name

Other Adults (Names)

Children (Names and Ages)

Address

City

State

Zip Code

Preferred Contact Number

What day and time is best to reach you by phone?

Preferred Email Address

How did you hear about Plant-Based Eatz?

If you Googled us, what were the keywords you used? **Please check the boxes of the items that you like only and place notes in the comment section.**

**For the following questions, please only check the boxes of the items that you like. Please place notes in the comment section that follows each category.**

SALADS

Fresh Green (choice of greens/lettuces, such as Romaine, red leaf, bibb, mixture, spinach, etc.)

Fruit in you salad

Salads as a main dish

COMMENTS - SALADS

SALAD DRESSING

Oil & Vinegar

Creamy Plant - Based Dressings (ranch, blue cheese, creamy Italian, etc)

COMMENTS - SALAD DRESSING

SOUPS/STEWS

Soups/Stews as a main dish?

Creamed

If you checked creamed, name type(s)

COMMENTS - SOUPS/STEWS

VEGETABLES (List vegetables you will not eat in the comments)

Green (peas, green beans, spinach, asparagus, peppers, cabbage, pea pods, celery, brussel sprouts, mustard greens/greens, broccoli, zucchini, avocadoes, poblanos, okra, kale, swiss chard)

Yellow (corn, wax beans, squash, peppers)

Red (pimento, red cabbage, beets, tomatoes, peppers, sweet potatoes/yams, carrots)

White (cauliflower, potatoes, parsnips, water chestnuts, bamboo shoots, bean sprouts, onions, mushrooms, leeks)

Beans (black, ranch-style, pinto, kidney, lima, white, pink, black-eyed peas, split peas)

Capers, black olives, green olives, coconut, artichokes, eggplant

COMMENTS - VEGETABLES

GRAINS

Rice (brown, white, wild, pilaf)

Couscous

Quinoa

Farro

COMMENTS - GRAINS

BREADS

Cornbread

Biscuits

Muffins

Pancakes / Waffles

Tortillas (corn, white or wheat)

COMMENTS - BREADS

SEASONINGS (Please list seasonings you will not eat in the comments)

Oregano, sage, rosemary, tarragon, fennel, cumin, cilantro, paprika, parsley, celery, chili powder, curry

Fresh garlic, parsley

Pepper - white, black or red

Salt - Kosher (food is prepared very low in salt so that you may season to taste)

COMMENTS - SEASONINGS

FATS/OILS

Butter Substitute

Olive Oil and other healthy oils (sesame, walnut, pecan, avocado, truffle, etc.)

COMMENTS - FATS/OILS

Is it okay to cook with wine?

Yes

Clear selection

Plant-Based MILK and Plant-Based MILK PRODUCTS (List any plant-based cheeses you do not like or are not willing to try in the comments)

Plant-based Cheeses (parmesan, cheddar, Swiss, muenster, fontina, blue, feta and goat etc.)

Plant “Milk” (almond, soy, hemp, oat, cashew, hazelnut, etc)

Vegan Yogurt

Vegan Sour Cream

Clear selection

COMMENTS (PLANT-BASED MILK PRODUCTS)

EGG SUBSTITUTE (Just Egg or Chickpea)

Yes

Clear selection

OTHER

Dried Fruits

Nuts (pecans, peanuts, walnuts, almonds, cashews, Brazil, etc.)

Pizza

COMMENTS - EGGS AND OTHER

FRUITS DISLIKED

SPICY FOODS (Check all that you like)

Bland

Mild

Moderate

Very hot

Do you have any favorite recipes that I can prepare for you as a plant-based dish?

CUISINES LIKED (Mexican/Curries/Italian, Home-style)

FAVORITE FOOD/RESTAURANTS

WHICH MEALS

Breakfast

Lunch

Dinner

Snacks

Dessert

NUMBER OF DAYS A WEEK YOU/FAMILY WILL EAT PREPARED FOOD

NUMBER OF SERVINGS FOR EACH MEAL

SERVICE FREQUENCY

Weekly

Bi Weekly

Monthly

Bi Monthly

SIDES WITH SERVICE

1 side with each entree

2 sides with each entree

ORGANIC OR NON-ORGANIC GROCERIES

LIST ANY KNOWN FOOD ALLERGIES

ENTER YOUR INITIALS TO COMPLETE YOUR QUESTIONNAIRE

Have any questions or concerns? Feel free to leave any questions you don't know the answer to blank or give us a call. We look forward to setting up your meal delivery service that fits best with your lifestyle and dietary needs and preferences!

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Houndstooth Media Group.

Does this form look suspicious? Report

Forms