The Kitchen Questionnaire Please complete the information with as much detail as possible. Thanks so much in advance. Date: MM slash DD slash YYYY First Name:(Required) Last Name:(Required) Email:(Required) A copy of this form will be sent to this email address.Street Address: City: State /Province/Region: Zip/Postal Code: What foods do you like to eat?What foods do you NOT like to eat?What is the biggest challenge you face with eating healthy?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 Would you benefit from quick, convenient 30-minute meals? Yes No Who are you cooking for? Just myself My family 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 meal per week When you eat out, where do you go? Please name:Would you like tips and recommendations for healthy restaurant eating? 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?Captcha Δ
