Dine  In!
4228 North Polaris Pkwy
Janesville, WI  53546
608-868-1113

Food Questionnaire

Name ______________________ Number and ages of family members _____________

My goal as your personal chef is to design and prepare meals suited to your individual tastes and dietary preferences. Please take the time to answer these questions thoroughly and honestly.  This questionnaire will guide me in custom designing your menus. Naturally, you will have the chance to give me feedback on each and every meal that I prepare for you.

For each food listed, please comment on whether the item appeals to you or not. Be as specific as possible, and add any clarifying comments. Cross out any food that you don’t care for.

Meats    (Check here ___ if you do not eat meat).

Beef (steak/ ribs/ stews/ sausage/ meatloaf/ meatballs)

Pork (tenderloin/ roasts /chops/ ground/ ham/ bacon/ sausage/ ribs)

I prefer to eat red meat no more than __ nights per week. (Leave blank if unlimited).

Poultry    (Check here ___ if you do not eat poultry).

Chicken (breasts/thighs/legs; boneless/ bone-in; skinless/ skin on)

Turkey (breasts/ smoked/ ground/ loaf/ stew/ sausage)

I prefer to eat poultry no more than __ nights per week. (Leave blank if unlimited).

Fish     (Check here ___ if you do not eat fish)

Is there any fish that you especially like (salmon/ cod/ Mahi-Mahi / tuna/ tilapia/ sole/ haddock/ mackerel/ orange roughy/ red snapper/ swordfish)

Seafood (shrimp/ scallops/ crab)

I prefer to eat fish no more than ___ nights per week.   (Leave blank if unlimited).

Vegetarian     (Check here __ if you do not want any meatless meals).

Are you vegetarian?     If yes, are you vegan?

Would you try vegetarian meat substitutes? (tofu/ tempeh/ TVP)

I prefer to eat a meatless meal no more than __ nights per week.  (Leave blank if unlimited).

Specific Foods

Vegetables (cross out dislikes) artichoke/ asparagus/ beans/ beets/ bok choy/ broccoli/ Brussels sprouts/ carrots/ cabbage/ chard/ cauliflower/ celery/ corn/ cucumber/ eggplant/ fennel/ kale/ kohlrabi/ mushrooms/ onions/ okra/ parsnips/ peas/ peppers-green and red/ potatoes-white and sweet/
pumpkin/  rutabaga / sauerkraut/ spinach/ squash-winter and summer/ tomato/ tomatillo/ turnip/ water
chestnut

Fruits (cross out dislikes) apples/ apricot/ avocado/ bananas/ cranberry/ cherry/ grapes/ raisins/ dates/ prunes/ blueberries/ strawberries/ raspberries/ pears/ peaches/ nectarine/ oranges/ lemon/ lime/ grapefruit/ pineapple/ kiwi/ melons/ mango/ guava/ papaya/ rhubarb

Whole grains ( barley/ bulgur (cracked wheat) / kasha (buckwheat groats) / oatmeal / quinoa/ rice-wild, brown, black, red)

Pasta (whole wheat/ soy/ flavored /entrée/ hot/ cold)

Dried Beans (warm/ cold/ entree)

Breads (whole wheat/ rye/ quick breads/ muffins/ corn bread)

Dairy (milk/ yogurt/ sour cream/ cheese-blue, cheddar, cream, feta, Jack, mozzarella, Parmesan, Romano, smoked, soy, Swiss)

Salads as a main dish (yes/ no/ sometimes)

Soups as a main dish (yes/ no/ sometimes)

Eggs (whole/ whites only/ quiche)

Wine or alcohol as a cooking ingredient (yes/ no)

Do you have a favorite wine or beer to drink?

Seasonings-herbs and spices (cross out dislikes) allspice/ anise/ basil/ bay/ capers/ cardamom/ caraway/ cilantro/ celery seeds/ chutney/ cloves/ cinnamon/ cumin/ curry/ dill/ fennel/ garlic/ ginger/ horseradish/ lemon/ lime/ marjoram/ mint/ mustard/ orange/ olives/ oregano/ nutmeg/ paprika/ parsley/ pepper/ poppy seeds/ rosemary/ saffron/ sage/ savory/ sesame /soy sauce/ tarragon/ thyme/ turmeric/ vanilla/ vinegar

Sauces (tomato/ oriental/ herb/ citrus/ creamy/ curry/ peanut/ salsa/ mayo)

Nuts (almonds/ brazil/ cashews/ pecans/ hazelnuts/ macadamia/ walnuts/ peanuts/ pistachio/ soy nuts/ coconut)

Sweeteners (sugar-white, brown, raw and fructose/ honey/ molasses/ maple syrup/ brown rice syrup/ marshmallow/ Equal/ Splenda)

Chocolate

Recipes and Styles

What foods do you never want on your menu? (Include all categories above and please be very specific).

What foods do you want to see often?

What are your 5 favorite dinner foods?

Do you have a barbecue and want to grill prepped meals on it?

What ethnic foods do you like? (Mexican/ Italian/ Chinese/ Scandinavian/ German/ Thai/ Indian/ Middle Eastern/ etc).

Do you have adventurous taste buds?

Please rate your preference for spicy food.  (bland/ mild/ moderate/ spicy)

Overall, describe an ideal dietary regimen for yourself. Mention whether you have any personal dietary requirements (example: low fat/ low carb/ high fiber/ low sodium/ low cholesterol/ gluten free, etc).

List any dietary allergies or intolerances.

Thanks for taking the time to complete this questionnaire. I look forward to preparing meals that are suited to your tastes and needs.

Linda Simon