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Client(s) Assessment Form

Full Name

Address Line

City/State/Postal Code

Daytime Phone

Evening Phone

E-mail Address

Please give us the email address you�d like your menus to be emailed to?

How did you find us? Through a Search Engine?  Personal Chef Network? Referral? If from any other source...do tell!

How often would you like our service? Select One Once A Month Twice A Month Twice Weekly Once A week Daily Occasionally

Are you following any special diet plan?

Do you have any medical conditions that should be addressed when planning your menus?

Do you or any members of your family have any food allergies?

How would you classify your style of eating? Low Carbohydrate? Low calorie? Low fat?  Gourmet? Organic?

How often per week do you eat the following meats?

Beef?    Chicken?

Pork?    Veal?

Lamb?    Turkey?

Duck?    Fish / Seafood?

Do you enjoy light or dark meat with regard to chicken or turkey? Select One Light Dark Mixed No preferrence

Do you dislike any of the following? Cod, sole, salmon, sea bass, scallops, snapper, shrimp, prawns, tuna, clams, mussels, crab or smoked salmon?

How many times per week do you enjoy seafood?

Do you prefer vegetarian food? If so, how many times per month?

How many times per week do you enjoy soup?

Do you like soup as a main course?

What is your favorite soup?

Do you like salads?

Salads as a main dish?

What salad ingredients do you like?

What are your favorite main dishes?

Are there any favorite dishes you miss eating and would like me to prepare for you?

How many times per week do you enjoy pasta as an entr�e?

Are there any fruits or vegetables that you dislike and would not want used in your entrees?

Are there any other flavors or items that you do not want used in your menus?

Do you like grains/nuts/beans/cheese?

Are you lactose intolerant?

What are your favorite fruits?

What fruits do you dislike?

What are your favorite vegetables?

What vegetables do you dislike?

May I cook with wines and liquors? Select One Yes No

I use an abundance of fresh herbs in my menus. Do you dislike any of the following herbs? Basil, thyme, sage, rosemary, oregano, tarragon, cilantro, watercress, chives, parsley, dill, thai basil, mint, caraway, cumin or fennel?

Do you dislike any of the following? Garlic, ginger, lemon grass, sesame oil, horseradish or chilies?

Do you dislike any of the following cuisines? French, Italian, Greek, Thai, Indian, Japanese or Chinese?

Where do your tastes fall on the spicy scale? Bland, mild, medium, hot or extra-hot? Select One Bland Mild Medium Hot Extra Hot

Would you like me to prepare foods that you can grill or barbecue? Select One Yes Occassionally No

How do you like your steak cooked? Blue rare, rare, medium rare, medium or well done?

What is your favorite cookie, muffin and cake?

What�s your favorite dessert?

 Tell us what your three favourite restaurants are in the Portland metro or Vancouver area.

If you are a single person can you provide space for 20 frozen entr�es in your freezer (about 2 cubic feet)? Select One Yes No Not Sure

Tell us about the kitchen where we will be working. How many stove top burners do you have? Are all burners working? How many ovens do you have? Are the ovens operational?Do you have an indoor or outdoor grill? How many refrigerators or freezers do you have?

Do you own a microwave oven? Select One Yes No

May we use your appliances such as blenders, food processors ETC.? Select One Yes No

Please type in your five favorite entree choices from our sample menu pages.

Please let us know here about any comments, questions or medical concerns that we need to know about.