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Todays Date: ________________________________________________________________ Please list ANY known or suspected allergies for anybody in household:
Starter questions: Ethnic Cuisines - Whats your favorite??? (Italian, Mexican, Greek, Chinese, Japanese, Indianetc) __________________________________________________________________________________
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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 want meals prepared in your home, or prepared and then brought to you?
If you want meals prepared in your home, do you have a security system that requires a pass code to enter your home if you will not be there? Yes ___ No ___ May we cook with Wine and/or Liquors? Yes ___ No ___
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Please list any poultry you will not or cannot eat: __________________________________________
When you eat Poultry do you prefer? Dark Meat ____ White Meat ____ Both ____
Fish/ Shellfish
Fin Fish: Salmon Tilapia Haddock Cod Catfish Bass Mahi Mahi Tuna steak Shell Fish: Shrimp Scallops Lobster Crab, natural Crab imitation Canned tuna in oil Canned tuna in water
Please list any fish or shellfish you will not or cannot eat: __________________________________________
Salads/lettuce: Salads: Mixed greens Fruit salads Rice salads Pasta salads Salad as main entree Lettuce/Greens: Arugula Butter head Endive Escarole Frisse Iceberg Leaf lettuce Lollo rosso/mesclun Radicchio Romaine Spinach Watercress
Please list any greens you will not or cannot eat: __________________________________________
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Do you eat salads as a main dish? Y N Please list any salad dressing you will not or cannot eat: ______________________________________
Soups: Creamed (name types) Hot Cold Clear broths With meat/poultry Vegetable Soup as main dish Other______________
Do you eat soups as a main dish? Y N Please list any soup you will not or cannot eat: __________________________________________
Vegetables: Artichokes Asparagus Bean sprouts Beets Bell peppers Bok Choy Broccoli Brussels sprouts Cabbage Carrots Cauliflower Celery Corn Cucumbers Dakion radish Eggplant Fennel Green beans Greens (collards etc) Kale Mushrooms Okra Onions Leeks Spinach Swiss chard Tomatoes Turnips Winter squash Yellow squash Zucchini Other __________________
Please list any vegetables you will not or cannot eat: ________________ _______________________
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Other __________________
Please list any grains or potatoes you will not or cannot eat: ___________________________________ Beans: Black-eyed peas Cannelloni Garbanzo Kidney Lentils
Other___________________
Please list any beans you will not or cannot eat: __________________________________________
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Please list any breads you will not or cannot eat: __________________________________________ : Herbs: -
Please list any herbs you will not or cannot eat: __________________________________________ Spices: Allspice Anise Bay leaf Caraway Cardamom Celery seed Chervil Cinnamon Cloves Coriander Cumin Curry powder Dill seed Fennel seed Garlic powder Ginger powder Lemon grass Mustard seed/powder Nutmeg Paprika Peppermint Poppy seed Saffron Spearmint Turmeric Wasabi. Other ________________
Please list any spices you will not or cannot eat: __________________________________________
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Other ________________
Please list any spices you will not or cannot eat: __________________________________________ Sweeteners:
Please list any sweeteners you will not or cannot eat: ________________________________________ Fats/Oils: Olive oil: Extra virgin Light Regular Butter Margarine Smart balance Other Oils: Canola oil Grape seed oil Sesame oil Vegetable oil Shortening Walnut oil. Peanut oil Other ________________
Please list any fats/oils you will not or cannot eat: ________________________________________ Dairy Products: Milk: Whole 2% 1% Skim Cream Half & half
Please list any dairy products you will not or cannot eat: _____________________________________
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Please list any cheeses you will not or cannot eat: __________________________________________ Eggs & Soy: Eggs: Whole Yolks only Whites only Egg substitute Tofu: Firm Extra firm, Soft Silken Soy based products Gluten-free Other _________________
Please list any eggs and soy you will not or cannot eat: ______________________________________ Nuts & Seeds: Almonds Cashew Chestnut Hazelnut Pecan Peanut Pistachio Pine nuts Macadamia Walnuts. Flaxseed, Poppy, Pumpkin, Sesame, Sunflower.
Please list any eggs and soy you will not or cannot eat: ______________________________________ Miscellaneous: Olives: Green Black Kalamata Others: Capers Jalapenos Artichoke hearts Other __________________
Any other misc items you can think of that you do not enjoy:___________________________________ Thank you. Directions 1. Fill out form 2. Save file to your desktop (VERY IMPORTANT STEP!) 3. Attach this form to an email addressed to alysiagpersonalchef@gmail.com
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