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  1. Surveys
  2. 2017
  3. April
  4. A
  5. Appetite Evaluation
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Questions marked with a * are required Exit Survey
 
Contact Information
* First Name : 
* Last Name : 
Phone : 
* Email Address : 
 
 
 
* How many pounds would you like to lose and what is your timeframe?
   
 
 
 
Describe your level of daily activity? Do you workout? If so, how often and what does your workout consist of (cardio, HIIT, yoga, weights, resistance training...)
   
 
 
 
* Are you currently limiting any foods or have food restrictions?
 
No restrictions
 
Low carb
 
Dairy free
 
No meat
 
Meat restrictions (no read meat, no seafood, no pork) *Please specify in the other field below
 
Gluten Free
 
Other
 

 
 
 
* Ingredients or foods you prefer to avoid (Select all that apply)?
 
Avocado
 
Shellfish
 
Nuts
 
Cilantro
 
Egg plant
 
Pork
 
Onions
 
Pork
 
Spicy foods
 
Mushrooms
 
Tofu
 
Brussels sprouts
 
Black Beans
 
Other

 
 
 
What meals are you most interested in having planned (Select all that apply)?
 
All meals including snacks/dessert
 
Breakfast
 
Lunch
 
Dinner
 
Snacks/desserts

 
 
 
* Select the kitchen tools you own? (Select all that apply)
 
Crock pot/slow cooker
 
1000+ watt blender
 
1000 or less watt blender
 
Food processor
 
Air Fryer
 
Oven
 
Stove top

 
 
 
* Would you be interested in smoothies for dessert or breakfast options?
 
Yes, fruit smoothies only
 
Yes, fruit and green smoothies
 
No
 
 
 
What are your guilty pleasures?
 
Bread (pizza, pasta, cheese sticks...)
 
Sweets (candy, chocolate, ice cream, ...)
 
Baked goods (cakes, pies, cookies...)
 
Salty (Chips, crackers...)
 
Other
 

 
 
 
Any other eating habits, food allergies, food preferences you would like to mention.