Food Preferences Questionnaire

The * indicate required information.
First Name: *
Last Name: *
Address:
City:      
Zip Code: 
Phone Number:  *
Email Address: *
Dietary Preference: Omnivore Vegetarian Vegan
Food Allergies:
Dietary Restrictions:
Medications Taken:
(if relevant)
Foods I Like:
Foods I Dislike:

Preferred Spice Level: Mild Medium Hot
Mild to Medium Medium Hot Very Hot

Ethnic Foods I Prefer:
(check all that appy)

American Regional Italian Latin
Asian Mexican  
Other Ethnic Foods: 

Cooking Oil Preference? 
Grocer Preference?  Where do you usually shop for groceries?

Rate the importance of local, sustainable & organic produce, dairy and meats: Very Important Somewhat Important Not Important