Client Assessment Form
Name: ____________________ Date: ___________________
Address: ________________________________________________________________
Home Phone: _______________ Cell Phone: ______________
Do you have any children living at home? Yes ___ No ___ Ages: ________________
Names: _________________________________________________________________
Pets? Dogs: Yes ___ No ___ Indoor? ___ Outdoor? ___ Names: ______________
Cats: Yes ___ No ___ Indoor? ___ Outdoor? ___ Names: ______________
Does any family member have food allergies? Seafood ___ Gluten ___ Peanuts ___
Other food allergies:_______________________________________________________
Which family member? ____________________________________________________
Is any family member Lactose Intolerant? Yes ___ No ___ Who:___________________
Are there any dietary restrictions? Diabetic ____ Cardiac Condition ____ High Blood Pressure ____ Light Salt ____ No Salt ____ Low Fat ____ No Fat ____ Low Carbohydrates ____ Other: _________________________________________________________________________________________________________________________
Are you on a weight loss program? Weight Watchers ____ South Beach ___ Atkins ____
Low Carbohydrates ____ Other:______________________________________________
Do you require portion control for your meals? _________________________________
Are you sensitive to any of the following? Garlic ____ Onions ____ Mushrooms ____
Bell Peppers ____ Tomatoes ____ Other Sensitivities: ____________________________
Your Spicy Food Scale: Bland ____Mild ____Medium ____Hot ___Extremely Hot ____
May we cook with Wine and/or Liquors? Yes ___ No ___
What Fruits and Vegetables do you dislike? ____________________________________________________________________________________________________________
What Fruits and Vegetables do you like? ______________________________________________________________________________________________________________
What restaurants do you regularly frequent? ____________________________________________________________________________________________________________
What Cuisines do you enjoy? Mexican ____ Italian ____ French ____ Thai ____
Chinese ____ Other: ______________________________________________________
How many times per week do you eat the following?
Beef ____ Pork ____ Chicken ____ Turkey ____ Fish/Seafood ____
When you eat Poultry do you prefer? Dark Meat ____ White Meat ____ Both ____
Fish/Seafood Favorites: ___________________________________________________________________________________________________________________________
Overall Favorite Dishes:____________________________________________________________________________________________________________________________
Do you have any favorite family recipes that you would like prepared for you?
________________________________________________________________________________________________________________________________________________
Do you eat Soups as a main dish? Yes ___ No ___ Salads? Yes ___ No ___
Do you eat Tossed Salads with entrées? Yes ___ No ___
Favorite Salad Greens: _____________________________________________________
Do you like Cherry Tomatoes? Yes ___ No ___
Do you eat Pasta as an entrée? Yes ___ No ___
Ravioli ____ Tortellini ____ Pasta with: Marinara Sauce ____ Pesto Sauce ____
Meat Sauce ____ Alfredo Sauce ____
Do you eat Vegetarian/Vegan entrées? Yes ___ No ___
Dried Products: Grains _____ Beans _____ Bulgur _____ Nuts _____
Do you eat Cheeses? Yes ___ No ___
Real Cheese _____ Low Fat Cheese _____ Non Fat Cheese _____
Favorite Cheeses: _________________________________________________________
Do you like homemade breads? Yes ___ No ___ Favorites: ______________________________________________________________________________________________
Do you like Baked Goods? Cookies _____ Brownies _____ Pies _____ Cakes _____
Favorites: _______________________________________________________________
How would you like your Entrees packaged? Individual ____ For Two ____
Family Style ____
Which appliance are you going to use to heat your meals? Oven ____ Microwave ____
Does your oven maintain an accurate temperature? Yes ___ No ___
What kind of Freezer space is available to store your entrees?
Attached to Refrigerator ____ Stand Alone ____
Where is your Fuse/Breaker Box located? ______________________________________
Do you have a security system that requires a pass code to enter your home? Yes ___ No ___
|