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DIETARY SURVEY FORM
Dietary Survey Form
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Address
*
Your answer
Phone number
Your answer
Do you cook?
*
YES
NO
SOMETIMES
Required
How often do you cook and eat at home?
*
EVERY MEAL
ONCE PER DAY
A FEW TIMES PER WEEK
A FEW TIMES PER MONTH
RARELY
Required
How often do you eat out?
*
EVERY MEAL
ONCE PER DAY
A FEW TIMES PER WEEK
A FEW TIMES PER MONTH
RARELY
Required
How many meals do you generally eat per day?
*
1
2
3 OR MORE
JUST SNACK
Required
How often do you skip meals?
*
EVERY MEAL
ONCE PER DAY
A FEW TIMES PER WEEK
A FEW TIMES PER MONTH
RARELY
Required
How would you categorize your eating preferences?
*
Atkins Diet
Anything Goes
Carnivore Diet
Ketogenic Diet
Low Carb Diet
Mediterranean
Paleo Diet
Pescatarian
Therapeutic: Targeting Medical Conditions
Vegan
Vegetarian
Required
DO YOU HAVE ANY ALLERGIES
*
Yes
No
Required
If yes, please list them below
Your answer
Do you have any food sensitivities?
*
YES
No
Required
If yes, please list below
Your answer
Have you been diagnosed with any of the following conditions?
*
Alzheimer’s
Andropause/Menopause
Autoimmune
Autism Spectrum
Cancer
Cardiovascular Disease
Celiac Disease
Diabetes
Dementia
Diverticulitis
Fibroids
Hypertension
Intestinal Permeability
Irritable Bowels
Obesity (+25lbs overweight)
PSOC
Renal Failure
Required
Do you have any aversion to the following in food?
*
Taste
Touch/Texture
Smell
Color
Required
Is there any food you prefer not to eat or do not eat due to religious restrictions?
*
YES
NO
Required
If yes, please list below
Your answer
How often do you eat animal protein?
*
EVERY MEAL
ONE SERVING PER DAY
A FEW TIMES PER MONTH
NEVER
Required
How often do you eat green vegetables?
*
EVERY MEAL
ONE SERVING PER DAY
A FEW TIMES PER MONTH
NEVER
Required
How often do you eat fruit?
*
EVERY MEAL
ONE SERVING PER DAY
A FEW TIMES PER MONTH
NEVER
Required
How often do you eat grains or grain products?
*
EVERY MEAL
ONE SERVING PER DAY
A FEW TIMES PER MONTH
NEVER
Required
How many people are you responsible to feed in your household?
*
MYSELF
1 PERSON
2 OR MORE
Required
What challenging experiences have you had regarding food in the past?
*
Your answer
What positive experiences have you had in the past?
*
Your answer
What do you hope to achieve by experience by using B&D Catering Services?
*
Your answer
Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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