Client Questionnaire

Name: Phone:   

Address:
Zip:     

    EMERGENCY NUMBERS

Office: Mobile: Fax:

Email: Do You use it? Yes No

Please Describe your "typical" meals: (Entree, 2 vegetable, etc.)

Do you have any medical conditions that need to be addressed?

Diabetes High Blood Pressure High Cholesterol Other

Family Members:

Names:                                     Age: (for children) Birthdays: (mm/dd)

Do you plan to be home the day I deliver?  Yes No

Nearby Neighbor?

Phone:

First Delivery Date:

Food Information

Do you want foods cooked with: Salt  Light Salt No Salt Low Fat No Fat Other

Does anyone have food allergies? Yes No

Anyone Lactose intolerant? Yes No If yes, can you have any dairy?

Are there any flavorings/seasonings/spices/cuisines you do not care for? Yes No

If Yes, please list.

What is your "garlic level?"    None Light Medium All I can eat!

What is your "onion level?"     None Light Medium All I can eat!

What is your "pepper level?"   None Light Medium All I can eat!

When preparing spicy foods, do you prefer: None Mild Medium Hot Really, Really Hot

Are there any food textures you find unpleasant or prefer?

Some recipes may include alcohol. Is it okay for me to use in your cooking? Yes No

Do you like nuts in Main Dishes, Sides or Salads? Yes No

From 1-5 (1 is most), tell me which of the following you like:

MEATS:  Beef   Pork Veal Lamb

Cuts of Meat Chops/T-bone Tenderloin Filet Sirloin Flank Brisket

POULTRY: Turkey  White Dark  Either

Chicken: White Dark  Either   

Skin: On Off

FISH:  MiId Strong Thick Thin   Red White Steaks Fillets Whole          

Fish Preferences:

If Salmon, do you prefer: Wild Farm Raised

SHELLFISH:

GAME:

May I substitute a different fish in a recipe in order to offer freshest selection on shopping day? Yes No

When preparing steak dishes, how do you like yours cooked?

When preparing lamb dishes, how do you like yours cooked?

When preparing veal dishes, how do you like yours cooked?

When preparing pork dishes, how do you like yours cooked?

When preparing fish dishes, how do you like yours cooked?

When preparing shellfish dishes, how do you like yours cooked?

Do you like Vegetarian Entrees? Yes   No

                   Soups?                      Yes   No

Do you like cheese: Yes No Lo-Fat

What Cuisines do you enjoy:

Asian French Italian Southwestern/Mexican Comfort/Southern

Mediterranean Latin Caribbean Regional Indian Jewish

Cajun/Creole Greek Fusion Other

Do you like to eat bread or rolls with your entrees? Always Sometimes Never

If yes, what kinds: White Rye Pumpernickel Wheat

Cheese Onion Sourdough Whole/Multi-Grain Other:

Do you like to eat salads with your meals? Always  Sometimes Never

Do you have a preference for particular greens?

What kind of salad dressings do you prefer? Vinaigrette Emulsion (Egg based) Creamy

Do you like wine with your meal? Red White None

Would you like wine suggestions for purchase? Yes No

STARCHES

VEGGIES

FRUIT

SALADS

SHELLFISH

GAME

Would you prefer meals packaged to heat in Microwave or Oven?   Are all of your appliances in good working order?  YesNo

Would like meals prepared for you to cook on your grill? Yes No Gas Charcoal

NOTE: Please leave refrigerator/freezer space available for storage.

Please tell me how you need entrees/sides packaged?

Single   Family Style (all servings of an item in one package)

How did you hear about my service? Internet ReferralName?

Do you have anyone to refer?    Name   Phone 

Other comments/concerns/questions?