Meal Prep Consultation Questionnaire

D'Vine Creations LLC dba D'Vine Health and Fitness Meal Prep Questionnaire

DVINEHEALTHANDFITNESS@GMAIL.COM
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone 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-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Your ideal diet would be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietOther
What sources of protein do you enjoy?

ChickenGround TurkeyFishVegetarian/VeganPorkLean red meatShrimpOther
What protein sources will you not indulge in?
What sources of carbohydrates do you enjoy?

Brown RiceQuinoaSweet PotatoCouscousJasmine RiceBasmati RiceTortilla wrap - CornTortilla wrap - FlourOatmealOvernight 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:

MustardGreek YogurtVinegarExtra Virgin Olive OilCoconut OilAvocado OilSriracha/Hot SauceOther
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 snackAfternoon snackEvening 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!*

YesNo
Should be Empty:

D'Vine Creations LLC dba D'Vine Health and Fitness Meal Prep Questionnaire