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Holistic Health
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Food Assessment

In order for me to customize a menu to your specific needs; it is imperative that I know your food preferences. Please check only the foods that you like and include any food sensitivities and dietary recommendations you may have.

Please provide additional comments if any.

CONTACT INFORMATION

NAME
HOME PHONE
CELL PHONE
ADDRESS
EMAIL ADDRESS

FOOD PREFERENCES

ARE YOU DIET SPECIFIC?
YesNo
Please Note: Vegan, Carnivore, Vegetarian etc.

SALADS

DO YOU ENJOY SALADS AS PART OF YOUR MEAL?
YesNoAs a side dishAs a main meal
DO YOU PREFER FRESH OR FROZEN VEGETABLES
FreshFrozen
DO YOU ENJOY FRUITS IN YOUR SALADS?
YesNo
WHAT ARE YOUR PREFERRED SALAD DRESSINGS?
LIST ANY FRUITS AND VEGETABLES YOU NEVER WANT TO SEE:

MEAT

DO YOU PREFER ORGANIC, FREE RANGE OR PASTURE RAISED MEAT?
Note: This may result in a higher cost for ingredients and additional charges for shopping around at different merchants to locate specific items.AlwaysWhenever possibleNot that particular
BEEF
RibsSteaksRoastGroundLean Only
DO YOU HAVE A FAVORITE TYPE OF STEAK?
HOW DO YOU LIKE YOUR STEAK?
Rare (at your own risk)MediumMedium rareWell done
PORK
ChopsRibsTenderloinPork Shoulder (whole)Pork Shoulder (sliced)Pork Shoulder (cubed)BaconPork BellyPork Sausage (sweet)Pork Sausage (hot and spicy)Ground PorkRack of Pork
VEAL
ChopsStewCutletsGround
POULTRY/CHICKEN
WholeDarkWhiteSkinlessBonelessGroundWingsDrumsticksThighsLeg QuartersBreastChicken SausageCornish Hen
POULTRY/TURKEY
WholeWhiteDarkSkinlessBonelessSmokedGroundWings (whole)Wings (sliced)Drumsticks (whole)Drumsticks (sliced)Turkey SausageTurkey Bacon
POULTRY/DUCK
WholeBreast
DO YOU HAVE ANY SEAFOOD ALLERGIES?
YesNo
SEAFOOD
Farm RaisedWild Caught Only
FISH
Sockeye SalmonCoho SalmonSnapperStrawberry GrouperBranzinoHalibutFlounderSoleTuna (fresh)Tuna (canned in water)Tuna (canned in oil)Cod
SHELLFISH
ShrimpLobsterMusselsClamsScallopsOysters
Additional Comments

FATS/OILS

Olive OilCoconut OilGrapeseed OilAvocado OilButterGhee

DAIRY

CHEESE
CheddarReserve CheddarGoudaSmoked GoudaMozzarellaFontinaGruyereSwissFetaParmesan
MILK
OrganicPasture RaisedrSBT freeWhole1%2%SkimLow Fat

NUT MILKS

ARE YOU ALLERGIC TO NUTS?
YesNo
WHAT ARE YOUR FAVORITE NUT MILKS?
Choose all that apply.Almond milkCashew milkCoconut milkOat milkHemp Milk

EGGS

OrganicPasture RaisedCage FreeFree RangeYolks OnlyWhites OnlyWholeEgg SubstituteQuailDuck

LEAST FAVORITE FOOD

What are your least favorite foods?

EARTH FOODS

GREENS
Check the ones you prefer. Please list any additions you would like.Callaloo/AmaranthDandelionSwiss ChardMustardCollardBeetTurnipBok ChoyArugulaSpinachMizunaTatsoiMicrogreensRed Leaf kaleGreen Leaf kaleDinosaur/Black kaleBlooming kale
CABBAGE
PurpleGreenNapaSavoy
LETTUCE
RomaineBostonGreen LeafRed LeafBaby GreensFriseeIcebergMesclun
MUSHROOMS
PortabellaBaby BellaShitakeWhite buttonOysterCrimini
TOMATOES
HeirloomRomaGrapeCampariCherryKumato (chocolate)
PEPPERS
GreenRedYellowOrangeHungarianScotch BonnetHabaneroJalapenoPoblano
ONIONS
SweetYellowRedLeeksShallots
ROOT VEGETABLES
CarrotJicamaPurple BeetGolden BeetChioggia BeetMurasaki/Japanese Sweet PotatoBoniato/Jamaican Sweet PotatoIdaho PotatoPurple PotatoFingerling PotatoParsnipYucca/CassavaWhite YamCeleriac /Celery Root)Yellow YamKohlrabiDasheen/Taro RootSweet YamRadishDaikon RadishGinger RootTurmeric Root
SQUASH
ButternutAcornKabochaPumpkin (calabaza)zucchiniYellow squashZucchini
MORE EARTH FOODS
BroccoliBroccoli Rabe/RapiniBroccolini/BroccoletteCauliflowerRomanescoOkrasTomatilloBrussel SproutsAsparagus (green)Asparagus (White)Bamboo ShootsCeleryGreen beansGreen beans (waxed)FiddleheadsFennelEggplantCucumberEnglish Cucumber (seedless)Cucumber (pickling)Bitter Melon

BEANS, LENTILS AND GRAINS

BEANS and LENTILS
BlackRed KidneyWhite Kidney (Canellini)PintoGreat NorthernLima/Butter BeansGarbanzo (Chick Peas)Fava BeansEdamameLentils (red)Lentils (yellow)Lentils (green)Lentils (orange)
GRAINS
Whole Wheat FlourWhite FlourBulgur WheatSpeltBarleyMilletOats
RICE
BlackBrownWildRedJasmineBasmatiParboiledLong GrainArborio
PASTA
MacaroniFettucineLinguineOrzoCouscousPenneZitiTortelliniShellsRavioliEgg NoodlesLasagnaAngel HairWhole WheatGluten Free

FRUITS, NUTS AND SEEDS

FRUITS
MangoAppleBananaKiwiPomegranateNectarineStar FruitPineapplePlumWatermelonHoneydewCantaloupePear (Bartlett)Pear (bosc)Grapes (red)Grapes (green)StrawberriesBlueberriesRaspberryBlackberriesCranberriesFigs (Black MissionFigs (Brown Turkey)
NUTS AND SEEDS
CashewAlmondPecanPeanutMacadamiaHazelnut (filbert)WalnutHemp SeedsPumpkin Seeds (pepita)Pine Nuts

HERBS AND SPICES

HERBS
ThymeRosemaryMarjoramBasilMintSavoryDillParsleyCilantroOreganoTaragonBay LeafHerbs de Provence
SPICES
NutmegAniseCarawayFennelClovesCuminCayenne PepperBlack PepperCurryMustardCelery SeedChili PowderGarlic PowderGinger PowderCardamonGaram MasalaAllspiceTurmericPure VanillaSesame SeedsPeppercornsSaffronPaprikaSmoked PaprikaCinnamon
SALT
Celtic Sea SaltHimalayan Pink SaltNo Added Salt
CONDIMENTS
HoneyBarbecue SauceMaple SyrupDijon MustardSoy SauceTamariHot SauceRoasted Peppers
OLIVES
KalamataBlackGreenStuffedHerbed
WINE/ALCOHOL
YesNo

CUISINES YOU ENJOY

CaribbeanAsianItalianMediterraneanAmericanMexicanHome-Style
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