Client Questionnaire

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Is this plan for you as an individual or as a family?

Individual

Family

Names and Ages of additional Family or Group Members (if applicable)

Do you have any dietary restrictions?

Gluten free

Dairy free

Nut allergies

Other

Any medical conditions requiring dietary adjustments?

Additional comments or preferences relating to restrictions and preferences?

What are your favorite foods or cuisines?

Are there any foods you dislike or want to avoid?

How many meals do you eat per day?

1-3

3+

How many times a day do you snack?

1-3

3+

Do you prefer home cooked meals or pre-prepared options?

Home Cooked

Pre-Prepared (Microwavable)

Are you interested in weekly meal prep options?

Yes

No

Unsure

How many times a week do you eat at restaurants?

0-3

3+

If you answered yes to eating at restaurants, list them here.

Do you have any cultural or religious dietary considerations?

What is your typical grocery shopping routine?

Weekly

Bi-Weekly

Monthly

Other

What kitchen appliances do you have available? (e.g., oven, microwave, blender, slow cooker, etc.)

Do you have any specific health or weight goals?

Are you following any fitness or exercise routines that impact your diet?

What is your typical grocery budget per week or month?

What types of foods do you prefer?

Organic

Locally Sourced

Conventional Grocery

Other

Are there any specific grocery stores you prefer shopping at?

Are there any specific brands or food products you prefer?

Are you interested in a Specialized Supplementation Plan? (herbs, vitamins, minerals)

Yes

No

Unsure

Any additional comments or special requests?

What do you consider to be your biggest challenges in achieving a balanced lifestyle?

What is your greatest motivation for lifestyle changes?

How did you hear about brie?