N O U R I S H | Food Questionnaire

Name*

First NameLast Name

Phone Number (best number to reach you)*

Area CodePhone Number

Email*

example@example.com

Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the best way to contact you?*

textphoneemail

How many people in your family are the meals for? *

Please list the names and ages of everyone who will be eating the food prepared.*

Do you have any minor, chronic or severe health conditions or illnesses? Please list.*

Are you currently under the care of a physician?*

YesNo

If yes, for what. Please describe.

Current medications:*

Do you have any allergies? Please list all and be specific.*

Do you have any dietary restrictions or special nutritional needs? *

Vegetarian?*

YesNo

Vegan?*

YesNo

Paleo?*

YesNo

Raw?*

YesNo

Pregnant, postpartum or breastfeeding?*

YesNo

Weight loss, keto or low carb?*

YesNo

Do you eat poultry?*

YesNo

Do you eat fish?*

YesNo

Do you eat red meat?*

YesNo

Do you eat eggs?*

YesNo

Do you eat pork?

YesNo

Gluten free?*

YesNo

Dairy free?*

YesNo

Grain free?*

YesNo

Soy free?*

YesNo

Nut free?*

YesNo

What are your current nutrition, health and/or fitness goals? *

What foods, flavors, and spices do you enjoy most?*

What foods do you NOT enjoy eating? *

What foods do you want me to avoid using or minimize using? *

What foods and flavors do you crave most often?*

Do you like spicy foods?*

Yes, I like it hot!A little spice is okNo spice for me

Please share anything else you would like me to know. *

Are you open to a plant-based meal in your package?*

YesNoMaybe

If yes, how many per week?*

How many meals per week are you interested in receiving? *

Please describe your desired package (number of meals and number of servings). *

What meals are you interested in receiving?*

BreakfastLunchDinner

Do you like variety and to try new types of foods, or do you prefer to eat the same types of foods? *

I understand The Nourish Co. and my personal chef or coach does not and will not diagnose conditions, prescribe medications, or perform medical treatment. I understand that if I am on any medications or under care of my doctor, I am to stay on my medications and medical plan as directed by my doctor. I understand that through proper nutrition I can achieve my desired health and fitness goals, and results vary based on my level of consistency, intensity, and fitness. I understand that through proper nutrition, I will begin to experience results such as increased energy, weight loss, reduction of belly bloat and digestive issues, better sleep, clearer thinking, clearer skin, less cravings, improved athletic performance and recovery, and greater health overall. I understand that my package cost is inclusive of my personalized package for my chef’s time and labor spent on creative menu planning for my specific needs, grocery shopping, food preparation and cooking, packaging and transportation, in addition to the cost of food per menu. I understand that I am responsible for giving detailed feedback on orders (regarding taste, flavors, re-heating instructions, portions, etc.) so my personal chef can make the necessary adjustments for future deliveries to best fit my needs.

Signature

Today's date*

Date

N O U R I S H.

Food Questionnaire