Name:_______________________________________
Address:_____________________________________
City: Zip:_____________________________________
Email:_______________________________________
Daytime Phone:________________________________
Evening Phone:________________________________
Here is your opportunity to let Chef Valerie know what
you prefer in your customized menu. Please check preferences
and add comments.Cross-out any foods that you DO
NOT like and never wish to see.
MEATS:
__ Beef (steak/roasts/ground round)
__ Pork (chops/roasts/ribs/bacon/ham/ground)
__ Veal (stew/ground/scallops)
__ Lamb (chops/stew/ground/roasts)
__ Meatloaf
__ Meat and vegetable/pasta casseroles
Comments: _______________________________________________________________
POULTRY:
__ Chicken (breasts/thighs/ground/etc.)
__ Turkey (breasts/smoked/ground/scalloped/etc.)
__ Chicken or turkey meatloaf
__ Chicken or turkey and vegetable/pasta casseroles
__ Duck (breast/thighs/Confit/Foie Gras)
Comments: _______________________________________________________________
FISH/SHELLFISH:
__ Fish (Anchovies, dover sole, halibut, salmon, striped
bass, orange roughly, catfish, snapper, trout, swordfish)
__ Shrimp
__ Scallops
__ Crab
__ Lobster
__ Clams
__ Mussels
__ Tuna (canned, fresh)
Comments: ________________________________________________________________
SALADS:
__ Fresh Green (Iceberg lettuces, Romaine,
red leaf, Bibb, mixture, spinach, etc.)
__ Fruit
__ Pasta
__ Salads as a main dish?
Comments: _______________________________________________________________
SALAD DRESSINGS:
__ Mayonnaise
__ Ranch
__ Vinaigrette
__ French
__ Oil/vinegar
__ Red wine/vinegar
__ Thousand Island
__ Other (identify)
Comments: _______________________________________________________________
SOUPS:
__ Creamed (name type)______________________________________
__ Hot
__ Cold
__ Chunky
__ Clear
__ With meat/poultry?
__ Soups as a main dish?
Comments: _______________________________________________________________
VEGETABLES:
__ Green ( artichokes, avocado, arugula, bok choy, broccoli,
brussel sprouts, capers, peas, green beans, spinach,
asparagus, peppers, celery, snow peas, cucumber, eggplant,
endive, green onion, cabbage, mustard
greens, kale, okra, olives)
__ Orange (Carrots)
__ Yellow (corn, wax beans, peppers)
__ Red (pimento, red cabbage, beets, tomatoes, peppers,
sweet potatoes/yams, radicchio, radish, sun-dried tomatoes)
__ White (cauliflower, potatoes, parsnips,
bean sprouts, mushrooms, leeks, hearts of palm,
jicama, water chestnuts)
__ Beans (black, ranch-style, pinto, kidney, lima, white,
pink, Edamame (soy), fava, garbanzo (chickpeas), lentils,
navy, cannellini)
__ Onions (cooked, raw, shallots)
__ Squash (baby squash, summer, yellow, zucchini, acorn, spaghetti, butternut)
Comments: _______________________________________________________________
GRAINS:
__ Bran (wheat/oat)
__ Bulgur wheat
__ Granola
__ Millet
__ Oatmeal
__ Orzo
__ Pasta
__ Pita (whole wheat)
__ Potatoes
__ Rice (Brown, white)
__ Couscous
__ Quinoa
__ Wheat (tortilla, flour)
__ Corn (tortilla, kernel, meal)
__ Other (identify)
Comments: _______________________________________________________________
FRUITS/BERRIES:
__ Red ( Apple (juice, fresh), Cherries, Cranberries,
Grapes, strawberries, watermelon)
__ Orange (Apricot, Cantaloupe, Grapefruit, mango, nectarine,
orange, papaya, peach)
__ Yellow (Banana, lemon, pear, pineapple)
__ Purple/Blue ( Blueberries, Fig, plum, raspberries,
black berries)
__ Coconut (flakes, Milk)
__ Dried Fruit (Dates, Fig, plum, raisins, currants)
__ Green (Grapes, Honeydew, Kiwi, lime)
Comments: ______________________________________________________________
BREADS:
__ Wheat
__ White
__ Rolls (white or wheat, sour dough, etc.)
__ Biscuits
__ Cornbread
__ Muffins
__ Pancakes
__ Waffles
__ Tortillas
Comments: _______________________________________________________________
SEASONINGS/FLAVORS:
__ Basil, bay leaves, cayenne pepper, Oregano, sage,
rosemary, tarragon, fennel, cumin, cilantro, paprika,
parsley, celery, chili powder, chili pepper, Cinnamon,
cocoa powder, crushed red pepper, curry, dill, parsley,
mint, saffron, thyme
__ Fresh garlic, garlic-trace, ginger, Horseradish,
Wasabi
__ Sugar (Brown, White)
__ Pepper—white, black or red
__ Salt—regular or Kosher, Sea Salt
__ Barbeque sauce, Marinara Sauce
__ Sweet Sauces
__ Chocolate, Vanilla, Graham Cracker
__ Coffee, Alcohol/Liquors
__ Honey, Maple Syrup, Molasses, Agave Nectar
__ Mayonnaise, Mustard, Ketchup
__ Pickles, Pickled Vegetables
__ Mirin, Miso, Soy sauce, Teriyaki Sauce, Sweet &
Sour Sauce
__ Salsa- Fruit, Tomato
__ Smoked
__ Vinegar, Worcestershire
Comments: _______________________________________________________________
FATS/OILS:
__ Butter
__ Margarine
__ Oil (Canola, Corn, Olive, Vegetable, Flaxseed, Sunflower,
Peanut )
__ Lard
__ Shortening
Comments: _______________________________________________________________
MILK AND MILK PRODUCTS:
__ Cheeses (parmesan, cheddar, Swiss, muenster, feta,
mozzarella, goat, fontina, soy, etc.)
__ Milk (skim, 1%, 2%, whole)
__ Buttermilk
__ Cottage cheese/Ricotta cheese
__ Cream Cheese
__ Yogurt
__ Sour cream
__ Half and half/ Heavy Cream
Comments: _______________________________________________________________
EGGS:
__ Whole
__ Yolks only
__ Whites only
__ Eggbeaters substitute
Comments: _______________________________________________________________
OTHER:
__ Tofu (Block, mashed)
__ Tempeh
__ Soy-based meatless products
__ Nuts (pecans, peanuts, peanut butter, pine nuts,
walnuts, almonds, macadamia, cashews, Brazil, soy nuts)
__ Seeds (poppy, sesame, pumpkin, sunflower)
Comments: _______________________________________________________________
List any vegetables or fruits you don’t ever want
to see ___________________________________
List any other food dislikes ________________________________________________________
List any known food allergies VERY IMPORATANT!
_________________________________
Are you currently on a restricted diet? If yes, describe
___________________________________
What diet programs, plans, or products have you tired
in the past? __________________________
Do you have any history of the following: heart disease
or stroke, diabetes, high blood pressure, high
cholesterol, digestive disorder, depression, sleep disorder,
cancer, other describe_______________
____________________________________________________________________________
Have you had surgery within the last year? If yes, what
type? _____________________________
Are you pregnant? ____________________________________________________________
Do you exercise? Please describe the types, frequency,
and duration________________________
What do you eat on a typically Day?
Breakfast__________________________ Lunch ______________________________________
Dinner _________________________________ Snacks ________________________________
Rate your preference for spicy foods - bland/mild/moderate/very
____________________________
Do you have any favorite recipes that I can prepare
for you? _______________________________
Do you have a barbecue and want meals prepared for cooking
on it? _________________________
International cuisine? - Mexican/Indian/Italian/Asian, etc.
___________________________________
What Best describes your eating habits? Prefer to try
a variety of different meal types / Prefer to find favorites
and have many repeats ____________________________________________________
Food Preferences: are you on a specialized diet? Low-Cal,
Low Carb, Low-Fat, Low-to-no-salt, Vegetarian, Diabetic,
Lactose-intolerant, Gluten Free _____________________________________
Favorite Cookies_______________________________________________________________
Favorite Dessert________________________________________________________________
If married, when is your anniversary?________________________________________________
Family members (names/birthdays) _________________________________________________
Notes: ______________________________________________________________________
___________________________________________________________________________
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