-Personal Chef Service/Food Coach-

Transcription

1 Nicole s Eat Good Feel Good Kitchen -Personal Chef Service/Food Coach- Cell nicole@nicoleegfg.com New Client Questionnaire Date: Client: Medical conditions: ( ) None ( ) Diabetic ( ) Heart Conditions ( ) High Blood Pressure ( ) High Cholesterol ( ) Other, identify Allergies: Intolerances: Sensitivities: How many times a week do you eat? Red Meat Lamb Turkey Pork Chicken Fish Seafood Pasta Grains Nuts Cheese Beans Salad Dessert Please circle Y for items that you wish to have included in your meals and N if you do not wish to have the item in the category prepared. Add comments where appropriate. MEATS: Y N Beef (steak/roasts/stew/ground/round) Y N Pork (chops/roasts/ribs/bacon/ham/ground/sausage) Y N Veal (stew/ground/scallops)

2 Y N Lamb (chops/stew/ground/roasts) POULTRY: Y N Chicken (breasts/thighs/ground/sausage) Y N Turkey (breasts/smoked/ground/sausage) FISH/SHELLFISH: Y N Fish (seabass, tuna, halibut, catfish, swordfish, tilapia, snapper, salmon-farmed or fresh) Y N Shrimp Y N Clams Y N Scallops Y N Crab Do you eat sushi/raw fish? Y N Would you like meals prepared that you would later cook on your grill or BBQ? Y N SALADS: Y N Fresh Greens (lettuce, romaine, spinach, endive, cabbage, mixture, arugula, kale, mix greens, etc.) Y N Fruit (cranberries, blueberries, raspberries, mango, kiwi, raisins, currants, figs, prunes, oranges, lemons, limes, etc.)

3 Y N Nuts (walnuts, hazelnuts, almonds, cashews, pine nuts, pecans, peanuts, etc.) Y N Salads as a main dish? SALAD DRESSINGS: Y N Mayonnaise (based) Y N Mustard (based) Y N Ranch Y N Vinaigrette Y N French Y N Oil/Vinegar Y N Balsamic Other (identify): SOUPS: Y N Creamed (name type): Y N Hot Y N Cold Y N Chunky Y N Red meat/poultry Y N Soups as a main dish?

4 VEGETABLES: Please X-out those items you do not wish to be prepared Green (eggplant, peas, green beans, edamame, broccoli, spinach, asparagus, green bell peppers, chile peppers, jalapeno, cabbage, celery, Swiss chard, escarole, endive, kale, Brussel sprouts, cucumber, green onion) Yellow (corn, wax beans, squash, yellow bell peppers) Red (red cabbage, beets, tomatoes, red bell peppers, sweet potatoes/yams) White (cauliflower, potatoes, water chestnuts, bean sprouts, onions, mushrooms, leeks, garlic) Beans (black, ranch-style, pinto, kidney, lima, fava, white, cannellini, chickpeas) GRAINS / PASTA / ALTERNATIVES: Y N Rice (white/brown/red/black) Y N Pasta (white, wheat, quinoa, rice, gluten free) Y N Couscous Y N Quinoa Y N Cornmeal Other (identify): BREADS: Y N Wheat Y N White Y N Sprouted Multi Grains Y N Gluten Free

5 Y N Artisan Bread Y N Cornbread Y N English Muffins Y N Tortillas (corn/flour) Do you like to have bread or rolls served with your meals? Y N SEASONINGS: Please X-out those items you do not wish to be used Dried/Fresh Herbs: oregano, sage, rosemary, tarragon, fennel, cumin, clove, coriander, cilantro, paprika, parsley, curry, chili powder, celery, dill, garlic powder, marjoram, saffron, turmeric, onion, garam masala, thyme, allspice, cinnamon Fresh: garlic, parsley, basil, sage, mint, ginger Pepper: white, black or red pepper flakes, cayenne Salt: regular, kosher, himalayan Other (identify): FATS/OILS: Y N Butter Y N Coconut Oil Y N Sesame Oil Y N Olive Oil (extra light, light, extra virgin) Y N Vegetable Oil Y N Sunflower Oil

6 MILK / DAIRY PRODUCTS & ALTERNATIVES: Y N Cheese (Parmesan, cheddar, Swiss, fontina, asiago, ricotta, mozzarella, mascarpone, goat, brie, blue cheese, etc.) Y N Milk (skim, 1%, 2%, whole) Y N Yogurt Y N Sour cream Y N Half and half Y N Heavy Cream Y N Coconut Milk (dairy free option) Y N Almont Milk (dairy free option) Y N Soy Milk (dairy free option) EGGS: Y N Whole Y N Yolks only Y N Whites only Y N Eggbeaters substitute

7 Overall Diet by Choice: Includes Red Meat Excludes Red Meat Mostly Vegetarian (Includes Fish) Ovo-Lacto Vegetarian (Includes Dairy and Eggs) Vegan Paleo Clean Eating High Protein, Low Carbohydrate Weight Loss Dr. Recommended Diet: Low Cholesterol, Low Fat Low Sodium Diabetic (Low Sugar) Celiac Disease (Gluten Free) Lactose Intolerant Weight Loss (Specific Plan Type: ) If you do eat meat, poultry, etc., would you like an occasional vegetarian meal? Y N

8 Please specify any medical conditions you have where diet is a serious factor (for example, diabetes, heart disease or other heart condition, high blood pressure): Which of the following closest describes your food style? (Mark all that apply with an X) Meat and Potatoes / Comfort Food (simple, classic) Gourmet (upscale) Spicy / Adventurous Health Conscious (no special diet, but conscious of eating right) Rate your preference for spicy foods: bland / mild / moderate / very spicy Alcohol restrictions for cooking? What are your favorite dishes? Please list any food you dislike: Do you have any favorite recipes that I can prepare for you? (Please make photocopies and attach to the back of the questionnaire) Favorite Cuisines: Italian, Mexican, Indian, American, Japanese, Chinese, Middle Eastern, Greek, French, Thai, South American, etc. Please identify: Thank you for completing this questionnaire! It will help ensure the best possible experience with my services! Nicole s Eat good Feel Good Kitchen

9 Nicole Tedeschi, Owner Personal Chef/Food Coach