New Client Assessment Form

Contact Information
* Client Name
* Email address
How many people in the household?
Start Date
Emergency cell #
Emergency work #
Spouse/domestic partner's name
Spouse/domestic partner's cell #
Spouse/domestic partner's work #
Friend/family member's name
Friend/family member's cell #
Friend/family member's work #
Medical Information
General practitioner's name
General practitioner's phone #
Are any of these medical issues present?	Diabetes Hypoglycemia Hyperglycemia High blood pressure High cholesterol Celiac Lactose intolerance
Any other medical conditions that need to be addressed? (ie, Crohn's disease, thyroid disorder, IBS, pregancy, etc)?
Do you follow a doctor's or dietician's recommended diet? (ie, foods to avoid, sodium intake, caloric intake, etc)?
Are there any known food allergies (ie, wheat/gluten, shellfish, nuts etc)? If yes, please specify person's name with allergy type:
Please list all medications as certain foods must be avoided with some medications:
Are you trying to lose weight? If yes, please check off the diet you prefer to follow:	Low-fat Low-carbohydrate "Pyramid" (FDA standard recommended diet) Other programs:
About your lifestyle
How many hours per week do you spend on menu planning?
... shopping?
... cooking?
... cleaning kitchen?
How often per week do you eat out?
Some of your favorite restaurants
About your food preferences
How often do you have desserts?
Some of your favorite desserts
Do you have any particular recipes that you want me to prepare?
Would you like meals marinated for cooking on your BBQ?	Yes No
May I cook with wine and/or liquors?	Yes No
Preference on salt intake	No Salt Light Salt
Preference for salts	Kosher salt Sea salt Salt substitute Table salt
Preference for sweeteners	Granulated sugar Brown sugar Powdered Splenda Splenda Brown Sugar Equal Sweet-N-Low Honey Stevia Other:
Preference for cheeses	Full flavor Low fat No fat Soy cheese Other:
Which cheeses do you enjoy?	American Asadero Asiago Blue Brie Camembert Cheddar Colby Jack Cotija Cottage Cheese Cream Cheese Edam Feta Fontina Havarti Goat Gorgonzola Gouda Gruye're Jarlsberg Marscapone Monterey Jack Mozzerella Muenster Oaxaca Panela Parmesan Provolone Ricotta Romano Queso Blanco Queso Fresco Queso Quesadilla Swiss
Which milk products do you enjoy?	Skim 1% 2% Whole Whipping/heavy cream Half and half Fat-free half and half Evaporated Fat-free evaporated Soy milk Rice milk Almond milk Goat's milk Powdered milk Organic lactose-free milk
How spicy do you like your foods?	Extra mild Mild Mild-medium Medium Hot Laser Incredibly painful
Are there any flavors or foods you dislike? (ie, curry, peanut oil, liver/gizzards, etc.)
How you want your ingredients such as onions chopped?	Small diced Medium diced Large diced
What protein portion size do you prefer?	Strict (4 ounces) Regular (6 ounces) Large (8 ounces) Super-sized (10-12 ounces)
What starch portion size do you prefer?	Strict (1/3 cup) Regular (1/2 cup) Large (3/4 cup) Super-sized (1 cup)
What vegetable portion size do you prefer?	Strict (1/2 cup) Regular (3/4 cup) Large (1 cup) Super-sized (1 1/2 cup)
Do you enjoy these choices as a main dish?	Chili Salads Soups Stews
Do you enjoy breads or rolls with your meal?	Yes No Favorite types:
Do you enjoy salads with your meal?	Yes No
Which salads do you prefer?	Fruit Tossed Salad Pasta Specialty (cucumber-tomato, carrot-raisin, etc.)
Which cuisine types do you enjoy?	Mexican Thai/Asian French Italian Indian Mediterranean Greek Cajun Cuban Caribbean Other:
How many times per week do you enjoy poultry?
... beef?
... pork?
... lamb/veal?
... fish/shellfish?
... meatless entrées?
... meat substitute?
How do you prefer red meat?	Rare Medium-rare Medium Done Well-done
Which types of meat do you prefer?	Roasts Shanks Chops Steaks Ribs Ground Cheeks Liver Tongue Tripe Cubed
Which types of poultry do you prefer?	Chicken Turkey Duck Cornish-hen Quail Goose Pheasant Roaster-hen
Which types of poultry cuts do you prefer?	White Dark Whole bird Ground Skin and bone in Skinless/bone in Skinless/boneless Hearts Liver Gizzards
Do you enjoy game or specialty meats? (Please specify ie, bison, ostrich, elk, venison, rabbit, boar, etc.)
Which types of shellfish do you prefer?	Shrimp Scallops Mussels Oysters Crab Lobster Crawfish Clams Prawns
Which types of fish do you prefer?	Salmon Tuna Orange roughy Cod Shark Sea bass Redfish Mahi Mako Monk Pollock Perch Sole Pike Skate Sturgeon Speckled trout Sea trout King fish Rock fish Rainbow trout Trout Catfish Tilapia Basa Walleye Whitefish Sun fish Hoki Other:
How do you like foods prepared?	Fried Sautéed Broiled Pan seared Grilled Roasted Boiled Baked Steamed Braised Stewed
Do you enjoy meatless entrees?	Yes No
Which meat substitutes do you enjoy?	Seitan Tempeh Tofu Textured Vegetable Protein Other:
Is anyone vegetarian?	Pescatarian (no meats but will eat fish) Flexitarian/semi-vegetarian (mostly vegetarian but occasional meat) Lacto-ovo-vegetarian (no meat or fish but will eat dairy and eggs) Lacto-vegetarian (no meat, fish, or eggs but will eat dairy) Ovo-vegetarian (no meat, fish, or dairy but will eat eggs) Vegan (no meat, fish, dairy, or eggs) Macrobiotic
If yes, which method?	Raw food Cooked food
Which grains, pastas, and types of rice do you prefer?	Barley Tabouleh (bulgar wheat) Polenta Quinoa Wild Rice Arboria rice (risotto) Saffron rice Brown rice Jasmine Rice (medium grain) Long grain rice (white) Mexican rice Angel hair pasta Elbow macaroni Fine couscous Israeli (pearl) couscous Farfalle (bow-tie shaped) Fettucine Fusilli Lasagne noodles Linguine Manicotti Orzo (rice shaped pasta) Penne Ravioli Spaghetti Pasta shells (jumbo, small) Tortellini Soba noodles Rice noodles
Kitchen information
How would you like your food packaged?	Individual Packages for two Family-size
What type of container would you like your food to be packaged in?	Glass (Pyrex, Anchor Hocking, etc) Plastic re-useable (Rubbermaid, Homz, etc) Disposable (gladware, ziplock, versatainers or vacuum bags)
Which appliances will you use for heating meals?	Microwave Stovetop Oven Toaster oven No preference Other:
Do you own a microwave oven?	Yes No Not functioning properly
Is your stove gas or electric?	Gas Electric Not functioning properly
Is your oven gas or electric?	Gas Electric Not functioning properly
Number of ovens	1 2 More than 2
Do you have a convection oven?	Yes No
Is your oven self cleaning?	Yes No
Do you have kitchen thermometers?	Oven Freezer Refrigerator
What other kitchen equipment do you have that I may use?	Toaster Oven Blender Bread machine Crock pot Electric skillet Electric griddle Food processor Electric mixer Skillets Pots Indoor grill (stove-top, freestanding) Immersion (hand) blender Rice cooker/vegetable steamer
If you have a free-standing freezer, where is it?
If you have an extra refrigerator, where is it?
If you have a fire extinguisher, where is it?
Where is your fuse box?
Will someone be home while I am cooking or will you give me a key?
Are there any security arrangements to be able to enter your home to cook for you?
Family information
How many children do you have?
Do they live with you full- or part-time?
Children names and ages
Family members' birthdays
Anniversaries
Number of pets
Are the pets friendly?	Yes No
Please list pets' breeds, names, and if they are indoor or outdoor pets:
Is there any special instructions regarding your pets? (ie, do not let bird out of cage, do not let dog in, do not feed, etc.)
Miscellaneous information
Where should I park my car?
How did you find out about my services?	Referral My website APPCA Website Yellow pages Newspaper article Advertisement/flyer
Any other concerns or instructions?