Questionnaire Form

Questionnaire Form

Please select all the items that you like. You may type in the comment boxes to give any additional information.

name First Last
address
Street Address

Address Line 2

City

State

Postal / Zip Code
email
home number - (###) - ### ####
fax number - (###) - ### ####
Meats
Beef Steak Roast Ground Pork Chops Roast Bacon Ham

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Poultry
Chicken Breast Thigh Whole

Turkey Breast Dark Meat Smoked Ground

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Seafood
Fish Catfish Grouper Halibut Sea Bass Snapper Tilapia

Shellfish Shrimp Scallops Crab

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Vegetables
Green Artichoke Hearts Asparagus Broccoli Cabbage Celery Collard Greens Green Beans Okra Olives Peas Peppers Snow Peas Spinach

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Other
Grains Rice Couscous Pasta
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Condiments Ketchup Mayonnaise Mustard (dijon, whole grain, yellow)
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Seasonings Basil Chili Powder Cilantro Cumin Curry Dill Fennel Garlic Oregano Paprika Pepper (black or white) Rosemary Sage Salt Sesame Seeds Tarragon Thyme
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Oils Butter Margarine Olive Oil Vegetable Oil Vegetable Spray
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Cheese Cheddar Cottage Cream Feta Goat Mozzarella Parmesan Ricotta Swiss
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Dairy Milk (skim/ 2% /whole) half & half Heavy Cream Sour Cream Yogurt Eggs (whole/whites/substitute)
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Nuts Almonds Cashews Peanuts Pecans Walnuts
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Meat Substitutes Seitan Tempeh Tofu TVP
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Spice Preference Mild Medium Hot
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Favorite Cuisines Comfort French Italian Mexican Middle Eastern Southern
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