Become Your Own Healthiest Chef - Intake Form

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Email

Date of birth

Location

How do you describe yourself?

Male

Female

Other

What’s your goal?

What’s the main obstacle to achieving your goal?

What’s your ideal result after finishing the program?

Enter you current weight / desired weight

Do you have any food allergies or sensitivities?

Do you follow any specific diet?

Are there any foods you strongly dislike?

Do you experience any of the following regularly?

Your cooking skills

Never cook

Beginner

Amateur

Pro

How many people are you cooking for?

1

2

3

4+

How much time can you allocate to making meals?

20 mins a day

2 hours per week

4+ hours per week

Other

Do you have a weekly budget for food? What is it?

Where do you buy your groceries? What’s the name of the store?

What kitchen equipment do you have?

None

Blender

Food processor

Both

More

Are you planning to buy kitchen equipment? How much are you open to invest in new healthy habits?

Would like a personalized menu based on your lab tests and doctor’s guidance? It’s an additional cost

Yes

No

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