D'Vine Creations LLC dba D'Vine Health and Fitness Meal Prep Questionnaire
DVINEHEALTHANDFITNESS@GMAIL.COM
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
How did you hear about us?
Do you have any medical problems and/or dietary restrictions that we should be aware of? Please submit list of foods approved or not approved to consume.
*
Do you have any food allergies? If yes, please include reaction:
*
If so, please include reaction
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Your ideal diet would be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Other
What sources of protein do you enjoy?
Chicken
Ground Turkey
Fish
Vegetarian/Vegan
Pork
Lean red meat
Shrimp
Other
What protein sources will you not indulge in?
What sources of carbohydrates do you enjoy?
Brown Rice
Quinoa
Sweet Potato
Couscous
Jasmine Rice
Basmati Rice
Tortilla wrap - Corn
Tortilla wrap - Flour
Oatmeal
Overnight Oats
What carbohydrate sources will you not indulge in?
What vegetables do you enjoy the most?
What vegetables do you not enjoy?
What fruits do you enjoy the most?
What fruits do you not enjoy?
What are your favorite snacks?
What is your favorite food?
What is your least favorite food?
Please select the condiments that you enjoy:
Mustard
Greek Yogurt
Vinegar
Extra Virgin Olive Oil
Coconut Oil
Avocado Oil
Sriracha/Hot Sauce
Other
How would you like your meals seasoned?
Natural (no seasoning)
Seasoned (No additional sodium)
Seaoned (Healthier sodium alternative)
Salted
How many meals a day are you looking to have prepared for you?
I.e., One, Two, Three, etc.
How long of a meal prep would you like prepared for you?
I.e., One day, Three days, Five days, Seven days, etc.
Would you like snack options included in your meal prep?
Yes, I love snacks!
No, thanks!
I am not sure...
If yes, please indicate how many snacks per day:
Morning snack
Afternoon snack
Evening snack
Please add any additional information below:
D'VINE CREATIONS LLC'S SOLE PURPOSE OF THIS FORM IS TO COLLECT INFORMATION TO PREPARE MEALS SPECIFIC TO EACH CUSTOMER'S REQUEST. SOME OF THE INFORMATION PROVIDED MAY CONTAIN CONFIDENTIAL MEDICAL INFORMATION AS RELATED TO ANY DIETARY RESTRICTIONS. I UNDERSTAND THAT THE INFORMATION SUPPLIED ON THIS FORM IS CONFIDENTIAL AND IS ONLY USED FOR PURPOSES AS STATED ON THIS DOCUMENT. The information provided by D'Vine Creations LLC is for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. I UNDERSTAND AND AGREE TO THE ABOVE TERMS & CONDITIONS!
*
Yes
No
Submit
Should be Empty: