Food Questionnaire 4OZ - 2 MEALS A DAY (7 DAYS)
Here is your opportunity to let me know what you prefer. Please check if you would like to see it in your meals.
4OZ - 2 MEALS A DAY (7 DAYS)
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Please Enter Your Info:
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Name
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Email
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Address
Address2
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City/Town
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State/Province
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ZIP/Postal Code
Country
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Phone
Date of Birth
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Today's Date
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MEATS: What Do You Prefer?
Beef
Pork
Sausage
Comments:
POULTRY: What Do You Prefer?
Chicken (breasts/thighs/ground/wings/etc.)
Turkey (ground)
Chicken or turkey sausage
Comments:
FISH/SHELLFISH: What Do You Prefer?
Fish (bass, catfish, snapper, salmon, halibut, tilapia, tuna)
Shrimp
Ahi
Tuna (canned in water)
Comments:
SALADS/SIDES: What Do You Prefer?
Fresh Greens (Romaine, red leaf, mixture, arugula, spinach, etc.)
Fruit
White Rice
Pasta
Quinoa
Brown Rice
Beans
Grains
Oatmeal
Couscous
Comments:
VEGETABLES:
Comments (List all dislikes)
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DO YOU HAVE ANY FOOD SPECIFIC HEALTH CONCERNS?
YES
NO
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OTHER FOOD SENSITIVITIES OR ALLERGIES?
YES
NO
GLUTEN
Please list:
DO YOU HAVE HEALTH CONDITIONS THAT FOOD CHOICE /PREPARATION CAN BE AFFECT? (Check all that applies)
DIABETES
HIGH BLOOD PRESSURE - LOW SALT
HIGH BLOOD PRESSURE - NO SALT
HIGH CHOLESTROL - LOW FAT
HIGH CHOLESTROL - NO FAT
LIST OTHER HEALTH CONCERNS:
Additional Notes:
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By checking YES and clicking the submit button below, You hereby agree to and accept the terms and conditions
Yes
NO
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