Dietary Analysis Form

Your Choice Feeding Program

TCOTLG Community Outreach & Services
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Email
example@example.com
Phone Number
Please enter a valid phone number.
Work Schedule
Number of People in Household
Monthly Income
Preferred days to attend free cooking classes

MondayTuesdayWednesdayThursday
What government assistance do you receive, if any?
Current Health Conditions
Medications
Dietary Information
Special Dietary Requirements

VegetarianVeganGluten-freeOmnivoreOther
Food Allergies
What foods are you allergic to?
Food Intolerances
What foods can you not handle?

Typical Daily Meals

	Meals
Breakfast
Lunch
Dinner
Snacks

List preferred food items and any foods to avoid

Specify typical meal times

	Meal Timing
Breakfast
Lunch
Dinner
Snacks

Water Intake
How much water do you consume in a day.
Nutritional Goals
Specify weight-related goals, if any
Specify goals for specific nutrients, e.g., increased fiber intake, reduced sodium, etc.
Specify any other health or dietary goals
Physical Activity
Provide details about the frequency, duration, and type of exercise
Enter any additional comments, concerns, or relevant information
ACKNOWLEDGMENT

I acknowledge that by submitting this application for the Your Choice Feeding Program, I understand and agree to the following terms and conditions:
1. Confidentiality: I understand that all information provided in this application is confidential and will only be accessed by specified personnel involved in the administration of the program. I consent to the collection and use of my personal information for the purpose of determining eligibility and providing assistance through the program.
2. Accuracy of Information: I certify that all the information provided in this application is true, accurate, and complete to the best of my knowledge. I undertsnad tha any falsification of information may result in automatic disqualification from the program.
3. Compliance with Program Stipulations: I agree to abide by the rules and stipulations of the Your Choice Feeding Program. This includes but is not limited to, following the program's guidelines for food selection, attending scheduled appointments, and adhering to any dietary or health-related recommendations provided.
4. Disqualification: I understand that failure to comply with the program's requirements or providing false information may result in disqualification from the program. Disqualification may also occure if I am found to be ineligible based on the program's criteria.
5. Program Modifications: I acknowledge that the TCOTLG Fruits of Love Food Pantry reserves the right to modify or terminate the Your Choice Feeding Program, including its eligibility criteria and offerings, at any time and without prior notice.
By submitting this application, I confirm that I have read, understood, and agree to the terms outlined above.
Date

MonthDayYear
Date
Should be Empty:

Your Choice Feeding Program

Dietary Information

Nutritional Goals

Physical Activity