Customized Menu Questionnaire

Please provide the following contact information:

First Name
Last Name
Title
Street Address
Address cont'd
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
FAX
E-mail

Do you or does anyone in your family have special dietary needs? If so, please identify those needs below (i.e. heart disease, diabetes, vegetarian, weight loss, cholesterol, allergies, etc.)

How do you prefer the following items prepared?

Beef (Rare-Well Done)
Pork (Medium-Well Done)
Tuna (Rare-Well Done)
Salmon (Rare-Well Done)
Duck (Rare-Well Done)
Pasta (Al dente-Soft)
Vegetables (Al dente-Soft)

Please indicate below if there are any cuisines or specific foods you do NOT wish to be included in your menu.

* CUISINES (Chinese, Thai, French, Mexican, Italian, Cajun, Fruited Dishes (sweet & sour), spicy, Mid-Eastern, German)

* MEATS & DAIRY (Beef, butter, chicken: dark/white, duck, lamb, pork, turkey, veal, calamari, caviar, clams, crab, flounder, grouper, hog fish, lobster, mussels, oysters, quiches, salmon, scallops, shrimp, soufflés, sushi, swordfish, tuna)

* CHEESES (American, bleu cheese, cheddar, cottage cheese, cream cheese, feta, mozzarella, parmesan, provolone, ricotta, romano, sour cream, Swiss, tofu)

* STARCHES (Breads: white/wheat/oat/cornbread, couscous, pastas, potatoes, rice: white/brown/wild, rye, pumpernickel, sweet potatoes, stuffing)

* FRUITS & VEGETABLES (Apples, apricots, bananas, blackberries, blueberries, cherries, figs, grapefruit, grapes, kiwi, lemons, limes, oranges, peaches, pears, plums, prunes, raisins, raspberries, strawberries, acorn squash, artichoke hearts, asparagus, avocado, broccoli, Brussels sprouts, cabbage, carrots, cauliflower, celery, corn, cucumbers, eggplant, green beans, hearts of palm, jicama, lettuce/romaine, lima beans, mushrooms, onions: raw/cooked, oriental vegetables, peas, snow peas, sauerkraut, spinach-cooked/fresh, sprouts, squash, sweet peppers, tomatoes: fresh/cooked/dried, zucchini)

* SALAD DRESSINGS (Regular/light, avocado, bacon, bleu cheese, Catalina, creamy Italian, French, honey Dijon, Italian, oil&vinegar, ranch, red wine & oil)

* SEASONINGS (Anchovies, basil, capers, cheese sauces, chocolate, chutneys, cilantro, cinnamon, coconut, cream sauces, curry, dill, egg sauces, fruited sauces, garlic, ginger, honey, horseradish, hot sauces: mild/medium/hot, horseradish, liquor, mayonnaise, meat gravies, MSG, Nuts, Olives: Black/Green, oregano, pepper(black), rosemary, sage, salt, sherry, soy sauce, spicy sauces, sweet sauces, tarragon, tomato sauces, truffles, wine sauces, wine: red/white/sherry)

Do NOT include in menu:

Additional comments for your chef to consider: