Date                             Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2005 2006 2007 2008    

Name
Address
City, State, Zip Code
Work Phone
Home Phone
Cell Phone
E-mail

 Do you enjoy soups or salads as a main dish?      choose no yes

 Do you enjoy soups or salads?                              choose no yes

 Do you enjoy pasta as an entrée?                         choose no yes

 How many times per week do you enjoy the following:
1 2 3 4 5 6 7 Beef        1 2 3 4 5 6 7 Pork      1 2 3 4 5 6 7 Turkey      1 2 3 4 5 6 7 Chicken     1 2 3 4 5 6 7 Fish/Seafood

List favorites so I may select the freshest catch of the day.
 

 Do you enjoy vegetarian entrees?                         choose no yes
Grains             Beans              Bulgar             Nuts                Soy     

 Are you lactose intolerant?                                     choose no yes

 Are you sensitive to any of the following?            choose no yes
Garlic              Onions                        Mushrooms                Bell Peppers

 List any other sensitivity:
 

 Are there any fruits or vegetables that you dislike? choose no yes

Like    

Dislike

Are there any other foods that you dislike?              choose no yes

Please list

 May I cook with wines and/or liquors?                  choose no yes

With any alcoholic substances?                                choose no yes

 Are there any medical conditions or situations?     choose no yes
Diabetic                     Cardiac Condition         High Blood Pressure              
High Cholesterol       Light Salt                       No Salt                                   
Low Fat                     No fat                             Other

 Are you trying to loose weight?                                choose no yes

 Would you like portion control?                               choose no yes

 Which regional cuisines do you enjoy?                   
Mexican          Thai              French         Italian           Oriental
Other

 Spicy food scale:                                                        choose Bland Mild Medium Hot Laser Incredibly Painful

 Do you eat bread or rolls with your entrées?            choose no yes

If so, what are your favorites?

 Do you like to eat tossed salad with your entrees?   choose no yes
 List favorite greens:
 

Do you like Cherry Tomatoes?                                   choose no yes  

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

How often would you like your entrees prepared?  choose Once a Week Bi-Weekly Once a Month

Would you prefer disposable or reusable containers? choose Disposable Reusable Once a Month

 Which appliance are you going to use to reheat your food? choose Microwave Conventional Oven

 Do you have a functioning freezer?                          choose no yes

 Is your freezer large enough to store the entrees?    choose no yes

 Would you like meals prepared to cook in BBQ?     choose no yes

 Are there any meals that you no longer prepare for yourself that I can prepare for you?

 Do you have a microwave oven?                              choose no yes

 Stove?                                                                         choose Gas Electric

 Do all burners work?                                                 choose no yes

 Is the oven functioning and accurate?                      choose no yes