HealthCoach Food Preferences Form

PERSONAL INFORMATION:

Delivery Time:

Please list all the foods you do not eat:

Please list any food allergies:

Please give a brief explanation why you chose HealthCoach:

LUNCH PREFERENCES (Please select all that apply):

DO YOU PREFER
Hotplates Sandwiches Salads All

BREAD CHOICES
Wraps Pita Rye Wheat Pumpernickel Baguette All

DO YOU EAT
Chicken Fish Shrimp Pork Turkey Meat

If you like meat, how do you like it cooked?

Do you want fruit?

Do you want water? Yes No

Do you want a snack?

SNACK CHOICES
Snackwells Granola Bar Nutri-Grain Bar Sugar-Free Cookies
Peanuts Sunflower Seeds Yogurt Pretzels