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 ___

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