Client Intake Application
This is the first step to becoming a client of Grandma's Soup. The information obtained in this application is protected and secure and will not be shared with outside parties. The information that you provided will allow Grandma's Soup to develope a meal plan that is best suited for your individual nutritional needs. This application is in no way an agreement to provide or a guarantee of goods and services. Upon the completion of this application, you will be contacted to schedule a consultation visit to further discuss our ability to provide you with services. At that time you will have the option of agreeing to or refusing our terms of service.
Last Name *
Your answer
First Name *
Your answer
Address *
Your answer
City & Zip Code *
Your answer
Email *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Age *
Your answer
Gender *
Date of Birth *
Your answer
Marital Status
Your answer
Total number of peopl living in your home *
Your answer
How many are children and what are their ages *
Your answer
What is your annual income
Your answer
Will you need financial assistance for meals and services *
Reason for seeking nutritional services *
Your answer
How many pepole in your household will need meals *
Your answer
Are you currently being treated for any medical conditions *
What is your diagnosis or medical condition *
Your answer
Is your condition life-threatening *
May we verify your illness with your treating physician *
We will only verify illness and obtain nutritional recommendation after in-person consultation
What is your current course of treatment *
Your answer
List any medications that you are currently taking *
Your answer
List any herbal/nutritional supplements that you are currently taking *
Please list all that you are taking & the purpose
Your answer
Has your physician recommended that you follow a specefic diet *
Are you currently following this diet
If Yes, please specify the type of diet & the steps you are taking to comply
Your answer
What is your normal meal schedule *
Please specify the times you eat breakfast, lunch, dinner & snacks
6:00 am - 10:30am
11:30am - 2:00pm
6:00am - 8:00pm
10:45am - 11:30am, 2:30pm - 5:30pm or 9:30pm - 12:00am
Don't Eat
Breakfast
Lunch
Dinner
AM Snack
PM Snack
Late Night Snack
How are weekends different *
Please specify your weekday eating habits from weekend eating habits
Your answer
Do you skip meals *
Please indicate the meal that you most often skip
Yes
No
Sometimes
Never
Breakfast
Lunch
Dinner
AM Snack
PM Snack
How often do you eat out *
Breakfast
Lunch
Dinner
Never
1-2 times a week
3-5 times a week
6 or more times a week
When do you usually snack *
Yes
No
Sometimes
Never
Mid Morning
After Lunch/Before Dinner
After Dinner/Before Bed
Late Night
Do you prepare your own meals *
Do you have food allergies *
Yes
No
Dairy
Tree Nuts
Gluten/Wheat
Food Dye & Additives
Other
Please indicate how often you consume the following foods *
Never
Sometimes
Occasionally
Frequently
All the time
Alcohol (beer, wine, spirits)
Bread, Yeast & Refined Flour Products
Red Meat & Lamb
Polutry
Dairy (eggs, cheese, yogurt, milk)
Carbonated Beverages
Fresh Fruit
Vegetables (Cooked/Raw)
Baked Goods (crackers, cakes, pies, cookies)
Deli & Packaged Meats
Beans & Legumes
Grains, Oats & Pasta
Potato Chips, Candy & Refined sugars
Nuts, Seeds & Nut Butters
Fruit Juice
Salad Dressings & Mayo
Soy Products
Butter, EVOO, Refined/Pressed Oils
Coffee & Tea (herbal or caffeinated)
Fish, Seafood & Shellfish
Pork
Gluten Free & Organic
Fast Food
Fried Foods
Please indicate your food taste & perparation preferences *
Least Favorite
Like Somewhat
Preferr
Favorite
Most Favorite
Bitter
Fatty
Spicy
Sour
Sweet/Salty
Salty
Well Done
Rare
Medium Rare
Medium Well
Moist or Soft Texture
Hot (temperature)
Cold (temperature)
Crusty, Hard or Crunchy
Raw
Stringy
Is there someone at home to help with meal preparation *
Will you need meals delivered *
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