| * Client Name |
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| * Email address |
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| * Home address |
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| How many people in the household? |
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| Start Date |
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| Contact Information |
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| Emergency cell # |
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| Emergency work # |
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| Spouse/domestic partner's name |
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| Spouse/domestic partner's cell # |
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| Spouse/domestic partner's work # |
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| Friend/family member's name |
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| Friend/family member's cell # |
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| Friend/family member's work # |
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| Medical Information |
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| General practitioner's name |
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| General practitioner's phone # |
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| Are any of these medical issues present? |
Diabetes
Hypoglycemia
Hyperglycemia
High blood pressure
High cholesterol
Celiac
Lactose intolerance
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| Any other medical conditions that need to be addressed? (ie, Crohn's disease, thyroid disorder, IBS, pregancy, etc)? |
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| Do you follow a doctor's or dietician's recommended diet? (ie, foods to avoid, sodium intake, caloric intake, etc)? |
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| Are there any known food allergies (ie, wheat/gluten, shellfish, nuts etc)? If yes, please specify person's name with allergy type: |
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| 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:
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| About your lifestyle |
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| How many hours per week do you spend on menu planning? |
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| ... shopping? |
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| ... cooking? |
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| ... cleaning kitchen? |
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| How often per week do you eat out? |
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| Some of your favorite restaurants |
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| About your food preferences |
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| Are there any flavors or foods you dislike? (ie, curry, peanut oil, liver/gizzards, etc.) |
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| What protein portion size do you prefer? |
Strict (4 ounces)
Regular (6 ounces)
Large (8 ounces)
Super-sized (10-12 ounces)
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| What starch portion size do you prefer? |
Strict (1/3 cup)
Regular (1/2 cup)
Large (3/4 cup)
Super-sized (1 cup)
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| What vegetable portion size do you prefer? |
Strict (1/2 cup)
Regular (3/4 cup)
Large (1 cup)
Super-sized (1 1/2 cup)
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| How many times per week do you enjoy poultry? |
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| ... beef? |
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| ... pork? |
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| ... lamb/veal? |
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| ... fish/shellfish? |
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| ... meatless entrées? |
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| ... meat substitute? |
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| What types of side dishes (or main dishes in some cases) do you enjoy? |
Grains
Vegetables
Pastas
Potato
Rice
Beans
Tossed Green Salads
Specialty Salads (fruit, vegetable, beans, rice, grains, pasta)
Soup
Other:
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| Is there anything else I need to know about your food preferences? |
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| Kitchen information |
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| How would you like your food packaged? |
Individual
Packages for two
Family-size
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| 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)
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| Which appliances will you use for heating meals? |
Microwave
Stovetop
Oven
Toaster oven
No preference
Other:
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| Do you own a microwave oven? |
Yes
No
Not functioning properly
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| Is your stove gas or electric? |
Gas
Electric
Not functioning properly
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| Is your oven gas or electric? |
Gas
Electric
Not functioning properly
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| Number of ovens |
1
2
More than 2
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| Do you have a convection oven? |
Yes
No
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| Is your oven self cleaning? |
Yes
No
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| Do you have kitchen thermometers? |
Oven
Freezer
Refrigerator
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| 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
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| If you have a free-standing freezer, where is it? |
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| If you have an extra refrigerator, where is it? |
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| If you have a fire extinguisher, where is it? |
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| Where is your fuse box? |
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| Will someone be home while I am cooking or will you give me a key? |
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| Are there any security arrangements to be able to enter your home to cook for you? |
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| Family information |
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| How many children do you have? |
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| Do they live with you full- or part-time? |
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| Children names and ages |
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| Family members' birthdays |
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| Anniversaries |
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| Number of pets |
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| Are the pets friendly? |
Yes
No
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| Please list pets' breeds, names, and if they are indoor or outdoor pets: |
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| 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.) |
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| Miscellaneous information |
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| Where should I park my car? |
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| How did you find out about my services? |
Referral
My website
APPCA Website
Yellow pages
Newspaper article
Advertisement/flyer
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| Any other concerns or instructions? |
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