Client Assessment

Do you enjoy Soups and Salads as Entrees? YES NO
Do you like them HOT COLD

Do you enjoy Pastas as Entrees?  YES NO
Do you like them HOT COLD

How many times per month do you eat the following?
BEEF PORK LAMB Fish/Seafood

(Please list favorites so that I may select the freshest catch of the day from your list of preferances.)

CHICKEN Dark White Both
TURKEY Dark White Both

Do you enjoy vegetarian entrees? YES NO
Grains Beans Bulgur Nuts
Cheeses Real Cheese Low Fat Cheese Non-Fat Cheese

Are you sensitive to or do you dislike any of the following?  (Please put ‘S’ for sensitivity/‘D’ for dislike)
Garlic Onions Mushrooms Bell peppers
Jalapenos/hot peppers Tomatoes ( Fresh canned)
List any other sensitivities:

Are you Lactose Intolerant? YES NO
Do you use Soy Products? YES NO

Do you have any food Allergies? YES NO
List:

Are there any Fruits or Vegetables you just plain Dislike? YES NO
Like: Dislike:

Are there any other Flavors or foods you just plain Dislike? YES NO
Foods/flavors you dislike:

May I cook with Wine and/or Liquors or any other alcoholic substances?
YES NO

Are there any medical Conditions or Situations I should be aware of?
YES NO
Diabetes Cardiac Condition High Blood Pressure
High Cholesterol Low Sodium No Sodium No Added Salt
Low Fat No Fat

Are you trying to lose weight? YES NO
Would you like portion control? YES NO

What Global Cuisines do you enjoy?
Mexican Italian Asian French Other

How spicy do you like your food?
Bland Mild Medium Hot Laser Painful

Do you like to eat Breads or rolls with your Entrees? YES NO
If so what are your favorites?

Do you like tossed salads with Entrees? YES NO
Favorite Greens?

Do you like Cherry/Grape Tomatoes? YES NO

How do you prefer your entrees packaged?
Individual For Two Family Style

Would you prefer disposable or reusable containers?
Disposable Reusable

Which appliances are you going to use to heat your food?
Microwave Oven

Would you like meals prepared for you to cook on your BBQ? YES NO

May I use fresh herbs from my organic herb garden in your food? YES NO

Do you have the following?
Microwave? YES NO
Stove? YES NO
All burners/oven function properly/temperature accurate?
YES NO
Do you have adequate freezer/refrigerator space to store meals?
YES NO
Where is your fuse/breaker box located?

Do you have children living at home? YES NO
Name(s)/Age(s):

Do you have Pets? YES NO
Name(s):

Breed:

Friendly? YES NO          Indoor Outdoor In & Out

Please note any security arrangements necessary for me to be able to enter your home to cook for you.

List any comments or concerns you may have.