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 NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

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

YesHotNoCold
Do you enjoy salad as a main entree?*

YesHotNoCold
How many times per month do you enjoy the following?
Beef*
Pork*
Turkey*
Fish*
Chicken*
Type of chicken

WhiteOn-boneDarkOff-bone
Fish types:
Shellfish types:
Do you enjoy vegetarian entrees?*

YesSometimesNo
Do you enjoy:

GrainsBeansBulgarNutsCheessSoy cheese
What types of cheese you like?
Are you lactose intolerant*

YesNo
Are you allergic to anything?*

YesNo
Do you have any other food sensitivities?*

YesNo
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?*

YesNo
If yes, please list:
May I cook with alcohol?*

YesNo
Do you have any of the following conditions?
DiabetesHeart problems
High blood pressure requiring:

Light saltNo salt
High cholesterol requiring:

Low fatNo fat
Are you trying to lose weight?*

YesNo
Would you like portion control*

YesNo
Are you on a particular diet?*

YesNo
If so, which one?
Do you particularly like or dislike any of the following cuisines?
Mexican/Latin*

LikeDislike
Thai*

LikeDislike
Chinese*

LikeDislike
Japanese*

LikeDislike
French*

LikeDislike
Italian*

LikeDislike
Other:
Indicate the level of spiciness you prefer:*

BlandMediumMildLaserHotIncredibly painful
Do you want bread, rolls, or tortillas as part of your meals?*

YesNo
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?*

YesNo
Please list favorite salad greens:
Do you like cherry tomatoes?*

YesNo
Do you have any favorite recipes you would like me to use?*

YesNo
If yes, please list or provide:
How would you prefer to have your meals packaged?*

IndividuallyFamily styleFor two
Would you prefer semi disposable or reusables?

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

GasElectric
Do all burners function?

YesNo
Oven

GasElectric
Functioning and accurate?

YesNo
Does your microwave work?

YesNo
Does your garbage disposal work?

YesNo
Do you have an additional freezer?

YesNo
If yes, location:
How will you most likely reheat your entrees?*

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

Client Assessment Form