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Surveys
2017
April
A
Appetite Evaluation
Appetite Evaluation
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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.
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