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Dear Client: So I can better serve you please provide the following information. Please copy and paste in
MSWord to complete and e-mail as an attachment to LTaylor@njoypersonalchef.com. Thank you!
Name __________________________________________________________________________________
Address _________________________________________________________________________________
Phone – Daytime ______________________________ E-Mail_________________________________
Overall Diet by Choice _________________________ Includes Red Meat (Beef, Veal,)
_________________________ Excludes Red Meat
_________________________ Mostly Vegetarian (Includes Fish)
_________________________ Ovo-Lacto Vegetarian (Includes Dairy and Eggs)
_________________________ Vegan
_________________________ High Protein, Low Carbohydrate
_________________________ Weight Loss
_________________________ Other
Dr. Recommended Diet _________________________ Low Cholesterol, Low Fat
_________________________ Low Sodium
_________________________ Diabetic
_________________________ Celiac Disease
_________________________ Weight Loss (Specific Plan?)
If you do eat meat, poultry, etc., would you like an occasional vegetarian meal? ________________________
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? (Choose all that apply.)
Meat and Potatoes/Comfort Food (simple, classic) __________________________
Gourmet (upscale) _________________________
Spicy/Adventurous (no limits) _________________________
Health Conscious (no special diet, but conscious of eating right.) _______________________________
What are your favorite dishes? ______________________________________________________________
II. Allergy Assessment
Mark any items which you believe that you are allergic, sensitive or those tastes and textures you DO NOT care for. (List any other known allergies.)
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Vegetables
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Vegetables (Cont'd)
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Herbs (Cont’d)
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Nuts (Cont’d)
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Amaranth
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Kale
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Anise
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Walnuts
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Anise
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Kohlrabi
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Basil
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Artichoke
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Leek
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Borage
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Seeds
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Asparagus
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Lettuce
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Caraway
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Pumpkin
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Beans, Adzuki
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Mushroom
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Chervil
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Sesame
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Beans, Green
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Okra
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Cilantro
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Sunflower
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Beans, Chinese
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Okra, Chinese
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Cinnamon
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Beans, Fava
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Olives
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Cloves
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Fruits
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Black-eyed Pea
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Onion
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Coriander
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Apple
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Beet
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Parsnip
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Cumin
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Apricot
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Bok Choy
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Pea
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Curry
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Banana
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Borage
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Bell Pepper
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Fennel
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Berries
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Broccoli
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Potato
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Ginger
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Bilberry
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Brussels Sprouts
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Pumpkin
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Marjoram
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Blackberry
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Cabbage
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Radish
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Mint
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Blueberry
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Cabbage, Chinese
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Radish, Chinese
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Mustard
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Boysenberry
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Carrot
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Daikon
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Oregano
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Cantaloupe
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Cauliflower
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Rhubarb
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Paprika
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Cherry
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Celeriac
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Rutabaga
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Parsley
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Currants
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Celery
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Sesame
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Pepper, Red
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Fig
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Chayote
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Shallots
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Pepper, Black
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Grapes
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Chicory
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Snow Peas
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Pepper, White
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Melon
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Chinese Mustard
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Edible-Pod
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Rosemary
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Nectarines
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Bok Choy
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Sugar Snap
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Sage
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Gooseberry
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Collard
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Soybean, Edible
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Savory
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Kiwi Fruit
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Corn
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Spinach
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Sesame
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Peaches
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Cucumber
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Squash
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Tarragon
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Pear
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Dandelion
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Squash, Spaghetti
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Thyme
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Pineapple
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Eggplant
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Squash, Summer
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Vanilla
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Plum
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Endive
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Sweet Potato
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Pluot
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English Pea
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Swiss Chard
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Nuts
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Plumquot
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Fennel
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Taro
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Almonds
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Plumquot
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Garlic
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Tomatillo
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Brazils
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Quince
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Ginger
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Tomato
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Cashews
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Raspberry
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Globe Artichoke
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Turnip
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Chestnuts
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Strawberry
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Gourds
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Watercress
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Coconuts
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Watermelon
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Horseradish
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Zucchini
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Hazels
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Japanese Eggplant
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Macadamia Nuts
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Other
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Jerusalem Artichoke
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Herb & Seasonings
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Peanuts
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Chocolate
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Jicama
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Allspice
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Pecans
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Food Coloring
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Pine Nuts
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Iodine
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Pistachios
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Shellfish
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Thank you and remember…
“Don’t Waste Your Time~N’Joy Your Life!”
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