Kitchen Questionnaire - Complete Health and Fitness

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Kitchen Questionnaire

Please fill out the information with as much detail as possible. Thank you in advance!

Date: *

First Name *

Last Name *

Phone *

Email *

Date of birth *

City

State

Postal code

Street Address:

What foods do you like to eat?

What foods do you NOT like to eat?

Do you like to cook?

Yes

No

Do you know how to cook?

Yes

No

If "YES" what prevents you from cooking?

Do you know what "clean" eating is?

Yes

No

Would a shopping list be helpful to you?

Yes

No

Please rate your level of understanding of nutrition:

I have no knowledge at all

I have a general knowledge

I know how to read nutrition labels

I can read labels and understand the effects of processed foods

I could teach someone else about nutrition

What is the biggest challenge you face with eating healthy?

Who are you cooking for?

Yes

No

Do you feel misinformed about nutrition - Facts vs. Myths?

Yes

No

I don't know

How often do you eat out?

Never

1-5 meals per week

5-10 meals per week

10-20 meals per week

When you eat out, where do you go? Please name:

Would you like tips and recommendations for healthy restaurant eating?

Yes

No

Would you benefit from quick, convenient 30-minute meals?

Yes

No

Why is it important to you to make changes toward a healthier lifestyle?

What 3 things do you want to learn today? Please list by order of priority:

How can I best serve you and support you in this journey of living a healthier lifestyle?