Client Interview Form

Client Assessment Form

This form will help me understand your needs, likes, and dislikes. Please fill it out completely so I can get to know you and your palate.
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
example@example.com
Emergency Contact

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
How many people in your household?
How did you hear about Knock. Knock. Food!
Do you enjoy soup as a main entree? *

Yes Hot No Cold
Do you enjoy salad as a main entree? *

Yes Hot No Cold
How many times per month do you enjoy the following?
Beef *
Pork *
Turkey *
Fish *
Chicken *
Type of chicken

White On-bone Dark Off-bone
Fish types:
Shellfish types:
Do you enjoy vegetarian entrees? *

Yes Sometimes No
Do you enjoy:

Grains Beans Bulgar Nuts Cheess Soy cheese
What types of cheese you like?
Are you lactose intolerant *

Yes No
Are you allergic to anything? *

Yes No
Do you have any other food sensitivities? *

Yes No
If yes, please list:
Are there any fruits or vegetables that you particularly like or dislike?
Likes:
Dislikes:
Are there other flavors or textures that you particularly dislike? *

Yes No
If yes, please list:
May I cook with alcohol? *

Yes No
Do you have any of the following conditions?
Diabetes Heart problems
High blood pressure requiring:

Light salt No salt
High cholesterol requiring:

Low fat No fat
Are you trying to lose weight? *

Yes No
Would you like portion control *

Yes No
Are you on a particular diet? *

Yes No
If so, which one?
Do you particularly like or dislike any of the following cuisines?
Mexican/Latin *

Like Dislike
Thai *

Like Dislike
Chinese *

Like Dislike
Japanese *

Like Dislike
French *

Like Dislike
Italian *

Like Dislike
Other:
Indicate the level of spiciness you prefer: *

Bland Medium Mild Laser Hot Incredibly painful
Do you want bread, rolls, or tortillas as part of your meals? *

Yes No
If you, please list yoir favorites: ex, whole wheat, white, pumpernickel, pita, flat bread, black bean tortillas, etc.
Do you like salad with your entrees? *

Yes No
Please list favorite salad greens:
Do you like cherry tomatoes? *

Yes No
Do you have any favorite recipes you would like me to use? *

Yes No
If yes, please list or provide:
How would you prefer to have your meals packaged? *

Individually Family style For two
Would you prefer semi disposable or reusables?

Semidisposable (Gladware) $15 per visit charge Reusable (Pyrex or Corningware) $100 deposit required
About your appliances: (If I'll be cooking at your place)
Stove:

Gas Electric
Do all burners function?

Yes No
Oven

Gas Electric
Functioning and accurate?

Yes No
Does your microwave work?

Yes No
Does your garbage disposal work?

Yes No
Do you have an additional freezer?

Yes No
If yes, location:
How will you most likely reheat your entrees? *

Oven Microwave
Additional comments: (Is there anything else I should be made aware of?)
Should be Empty:

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Client Assessment Form