ABOUT
SERVICES
GALLERY
TESTIMONIALS
CONTACT
Chef Jason Pereira
ABOUT
SERVICES
GALLERY
TESTIMONIALS
CONTACT
Client Questionnaire
Name
*
First Name
Last Name
Email Address
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Alternate phone
(###)
###
####
Names of family members & children's ages
How many people will be eating these meals?
How often will you require services per week?
Which meals do you need?
Breakfast
Lunch
Dinner
Snacks
Are there any food allergies to consider? Which family member has this allergy?
Does anyone in your family avoid any food groups due to intolerance? Please indicate.
Does anyone in your family have any dietary restrictions? Please indicate.
Your Diet Do's & Don'ts
Please check each box which best represents your eating habits.
Vegetarian
Ovo-Lacto Vegetarian (includes eggs + dairy)
Vegan
Excludes Red Meat
Excludes Pork
High-Protein
High Protein & Low Carbs
Plant Dense
Preferred cuts of meat:
Preferred types of fish & seafood:
What are your favorite dishes?
What are your favorite restaurants?
What are your favorite types of cuisine?
What are your favorite salad greens?
What are your favorite salad dressings?
Do you eat salad as your main course?
YES
NO
Do you eat soup as your main course?
YES
NO
How would you like your meals packaged?
FAMILY STYLE (reserved in fridge for reheating)
PRE-PORTIONED INDIVIDUAL (reserved in fridge for reheating)
PLATED AT TIME OF SERVICE
What appliances will you use to re-heat your meals?
Do you own any of the following?
VITAMIX
BLENDER
FOOD PROCESSOR
NON-STICK PAN
BAKING SHEET
GLASS CONTAINERS (5+)
I DO NOT OWN ANY OF THESE DEVICES
Do you want vegetarian options?
YES
NO
What are your favorite vegetarian proteins?
BEANS
LEGUMES
GRAINS
SEEDS
NUTS
FISH
EGGS
QUINOA
TOFU
OTHER
Do you like fresh herbs in your food?
YES
NO
Do you like sauces with your meat & veggies?
YES
NO
Do you mind raw onions or garlic in your food?
YES
NO
Do you mind cooked onions or garlic in your food?
YES
NO
Do you like strong, bold flavors? (ethnic cuisine etc)
YES
NO
Do you like nutrient-dense sweets?
YES
NO
Do you consume dairy?
YES
NO
Will you be home during meal prep?
YES
NO
If you will not be home during meal prep, do I have permission to enter your home?
YES
NO
Please provide proper concierge or housekeeper contact info if services will be rendered in your absence:
Please list any comments or concerns
Disclaimer (please type your name to agree)
I am a personal chef. I am not a practicing nutritionists or registered dietician. I prepare nutrient-dense, wholesome, and honest dishes for my clients, however I am not licensed to provide nutritional guidance or medical advice, diagnosis, or treatment of any kind. For any health concerns, please contact your physician or health-care professional. It is recommended that you speak to your doctor prior to beginning any new dietary changes. By typing your name below you agree that you have read & understand this disclaimer.
Thank you!