The Pickled Beet Food Questionnaire

We Create A Personalized Menu For Each Client Every Week

Imagine going into a restaurant, looking at the menu, and realizing that every dish on it is one of your favorites. At The Pickled Beet, every client gets their own personalized menu every week. Please take a few minutes to tell us about your preferences, foods you'd like excluded, allergies, and any dietary restrictions so we can plan a menu just for YOU!
INSTRUCTIONS

Please complete the following form so we can learn exactly what you like, don't like, and any food restrictions or concerns you have.

Once submitted, you will be redirected to schedule a 15-minute consultation with our head chef. Don't skip this step - we want to make sure we have all the details down to get you exactly what you want!

Our schedule books up extremely fast so be sure to book ASAP to choose your preferred date and time.

The Pickled Beet Family is looking forward to cooking for you!
Full Name*

First NameLast Name
Date of Birth
MM.DD.YYYY
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Menus will be sent to this email address for approval
Phone Number*
Is this a cell phone?*

YesNo
How did you hear about The Pickled Beet®?*

Internet SearchFriend or Family MemberFacebookInstagramOther
If Internet Search, what keywords did you search for?
Do you have any medical conditions that need to be addressed?
Ex: Diabetes, High Blood Pressure, High Cholesterol, Pregnant or Postpartum, etc
Do you have any FOOD ALLERGIES? Please DO NOT list preferences or intolerances here. If you do not have any food allergies, write "none".*
A food allergy is an unpleasant or dangerous immune system reaction after a certain food is eaten. ex: peanuts, gluten, shellfish, eggs, etc.
Do you have any FOOD SENSITIVITIES? Please DO NOT list preferences here. If you do not have any food sensitivities, write "none".*
A food sensitivity occurs when a person has difficulty digesting a particular food. ex: Lactose, food coloring, caffeine, etc.
Is it OK to use wine/alcohol in your meals?*

YesNoOther
Would you like Vegetarian/Vegan entrees?*

YesNoOther
What are your favorite cuisines?*

AmericanAsianCajun/CreoleCubanIndianItalianMediterraneanMexicanOther
MEATS & POULTRY

Please tell us which items to EXCLUDE in your meals.
Meats & Poultry I do not want:*

Beef (steak/roasts/ground)Bison / BuffaloLamb (chops/stew/ground/roasts)Pork (chops/roasts/ribs/ground/sausage)Veal (stew/ground/scallops)VenisonBaconChickenTurkeyDuckExclude AllI Like All of These
Chicken cuts I do not want:*

BreastsThighsGroundSausageMeatloafExclude AllWingsI Like All of These
Turkey cuts I do not want:*

BreastsTenderloinGroundSausageMeatloafExclude AllI Like All of These
Comments:
Ex: Only boneless chicken, no skin, etc.
SEAFOOD

Select the items to EXCLUDE in your meals.
Seafood I do not want:*

CrabShrimpLobsterSquid (Calamari)OctopusScallopsFishExclude AllI Like All of These
Fish I do not want:*

BarramundiBranzinoCodFlounderGrouperHalibutMahiSalmonSeabassSnapperSwordfishTunaExclude AllI Like All of These
Comments:
Ex: We like thin filets, no steaks, no whole fish, no skin, etc.
Non-Meat Products

Please identify any non-meat ingredients you WOULD LIKE in your meals, if any, such as tofu, Beyond Meats, tempeh, etc.
Non-meat Products I would like to INCLUDE in my meals:
VEGETABLES & FRUITS

Select the vegetables and fruits that you would NOT LIKE to be included in your meals. We will exclude the items you select. If you have special notes, such as I only like cooked onions, etc. don't check the item and include that note in the comments section below.
Vegetables and Fruits I do not want:*

Acorn SquashArtichoke HeartsArugulaAsparagusAvocadoBean SproutsButternut SquashBell PeppersBeetsBok Choy (Chinese Cabbage)BroccoliBrussel SproutsCabbageCarrotsCauliflowerCelery RootCollard GreensCornCucumbersEdamameEndiveEggplantFennelGreen BeansGreen onions/ScallionsJicamaKaleLeekLettuceMesclunMushroomsOnionsParsnipPeasPlantainsPotatoes (red/russet/gold/fingerling/peewee)RomaineShallotsSnap PeasSnow PeasSpaghetti SquashSpinachSweet PotatoesSwiss ChardTomatoesTomatillosYellow SquashYucaWater ChestnutsZucchiniI like All of These
Comments:
Ex: Only sweet potatoes, prefer raw tomatoes, like vegetables as dente, no raw onions, etc.
Olives I do not want:*

Black OlivesGreen OlivesKalamata OlivesExclude All OlivesI like All of These
Comments:
GLUTEN & GRAINS

Select the legumes, grains, pastas, breads and seeds that you would like EXCLUDED in your meals.
BEANS I do not want:*

Black BeansCannelliniChickpea/GarbanzoFava BeansKidney BeansLentilsPinto BeansExclude All BeansI Like All of These
GRAINS/PASTA I do not want:*

Egg PastaGluten Free PastaMillet (Gluten Free)Oats (Gluten Free)Polenta (Gluten Free)Quinoa (Gluten Free)Rice (basmati, jasmine, white, wild, yellow) (Gluten Free)Risotto (Gluten Free)Whole Wheat PastaExclude AllI Like All of These
BREADS I do not want:*

BiscuitsCornbreadCorn Tortillas (Gluten Free)Flour TortillasGluten Free, Grain Free TortillasGluten Free Flour TortillasWheat BreadWhite BreadExclude AllI Like All of These
Comments:
NUTS & SEEDS I do not want:*

AlmondsBrazil NutsCashewChiaFlaxHazelnutHempPeanutsPecansPine NutsPistachioPumpkin SeedsSafflower SeedsSesame SeedsSunflower SeedsWalnutsExclude AllI Like All of These
Comments:
FLAVOR PREFERENCES
Are there any seasonings/spices that you DO NOT like?
Preferred Spice Level:*

MildSpicyVery SpicyOther
Comments:
DAIRY

Select dairy items you would like us to EXCLUDE in your meals.
DAIRY items I do not want:*

Cheeses (parmesan, cheddar, swiss, blue, feta, goat, mozzarella, provolone)Regular Cheeses but Non-Dairy milkMilk (skim, 1%, 2%, whole)Cream CheeseRicottaYogurtSour CreamHeavy Cream, Half-and-HalfExclude all DairyI Like All of These
NON-DAIRY items I do not want:*

Cheeses (dairy-free)Milk (almond, cashew, coconut, pea)YogurtVegan butterSour CreamGheeExclude All Non-DairyI Like All of These
EGGS I do not want:*

WholeWhites OnlyEgg SubstituteExclude AllI Like All of These
Comments:
NEXT STEPS

Service Details, Billing Details & Scheduling Consultation
What type of meals are you interested in?*

BreakfastLunchDinnerDessertsSnacksSmoothiesFresh JuiceOther
Meal Schedule:*

MondayTuesdayWednesdayThursdayFridaySaturdaySundayOther
Sides:*

1 Side dish2 SidesOther
Number of servings:*
Additional Comments
Please provide any comments, concerns, or special requests that you might have . . .
HANG IN THERE, YOU'RE ALMOST DONE!

Please complete the following billing questions. Notice that we will not be asking you for your credit card number at this moment, as we will be securely collecting that information over the phone at the end of your consultation.

Once you submit the Food Questionnaire, you will be redirected to a Calendly link where you can schedule an appointment at your convenience for a 15-minute consultation, during which you will go over your answers to the questionnaire and plan options.
Name:

First NameLast Name
Is your billing address the same as delivery address?

YesNo
Billing Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
MEDICAL ADVICE DISCLAIMER

DISCLAIMER: THE PICKLED BEET DOES NOT PROVIDE MEDICAL ADVICE

This information, including, but not limited to, text, graphics, images, or other material contained in this form, or any communication (verbal or written) is for informational purposes only. No material on this form, or dicussion relating to it, is intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment, and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because or something you have read or discussed with any member or contractor with The Pickled Beet.
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We Create A Personalized Menu For Each Client Every Week

INSTRUCTIONS

MEATS & POULTRY

SEAFOOD

Non-Meat Products

VEGETABLES & FRUITS

GLUTEN & GRAINS

FLAVOR PREFERENCES

DAIRY

NEXT STEPS

MEDICAL ADVICE DISCLAIMER