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(214) 592-9972
3440 Eldorado Pkwy #4 McKinney, TX 75070
No Recipe Night in August 2025
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Intake Form
Intake Form
sa360
2025-07-02T10:44:18-05:00
These answers are private and never shared.
Name(s) of Individual or Both Spouses/Mates
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Are you Married? or have a Partner?
(Required)
Yes
No
Do you cook together?
(Required)
Yes
No
Do you have children?
(Required)
Yes
No
Do you enjoy cooking?
(Required)
Yes
No
Sometimes
Do you try to maintain nutrition & eliminate unhealthy fats when cooking?
(Required)
Yes
No
Do you suffer from indigestion, gas or tiredness after eating?
(Required)
Yes
No
Do you have inflammation?
(Required)
Yes
No
Do you have a health concern?
(Required)
Yes
No
If yes, what is it?
(Required)
What is your main health goal?
(Required)
Do you have brain fog?
(Required)
Yes
No
Do you a chronic disease?
(Required)
Yes
No
Do you find it difficult to get your family/children to eat healthy?
(Required)
Yes
No
How many portions of fruit and vegetables do you eat in a typical day?
(Required)
5 or more
Between 2 and 4
Less than 2
Do you sense that you are getting enough dietary fiber* in your diet?
(Required)
Yes, I always try to eat beans, legumes, whole grains varieties of bread, rice and pasta every day.
Possibly not. I prefer to eat the white varieties of bread, rice and pasta.
Not really
*What is Dietary Fiber? Dietary fiber, also known as roughage, is the indigestible part of plant foods. Fiber has a host of health benefits, including reducing the risk of heart disease and type 2 diabetes and optimizing gut health. Fiber is mostly found in vegetables, fruits, whole grains, and legumes.
Please check any family history including thru grandparents
(Required)
High Cholesterol
Digestive Disorders
High Blood Pressure
Cancer
Dementia / Alzheimer’s
Diabetes
Leaky Gut
Autism/ADHD/ADD
None of the above
List any foods that you are allergic to or cannot eat
Which 2 are most important to you when planning Daily Meals?
(Required)
Improving Health
Save Time
Save Money
Flavor
Would you be interested in a method of food preparation that cuts your kitchen time in half & saves nutritional value?
(Required)
Yes
No
Maybe
How much do you spend weekly on groceries?
(Required)
How much do you spend monthly on both eating out/take out?
(Required)
Have you heard of any health concerns about different cooking materiel?
(Required)
Yes
No
On a scale of 1-10, how important is it to you to eat healthy?
(Required)
Please enter a number from
1
to
10
.
On a scale of 1-10, how important is avoiding metal/chemical toxicity?
(Required)
Please enter a number from
1
to
10
.
Do you suffer any of the following symptoms? (Check All That Apply) (These can be associated with Heavy Metal Toxicity)
(Required)
Nervous System Disorders
Immune Dysfunction
Depression
Fatigue
Muscle Weakness
Achy Joints
Anemia
Memory Loss
Headaches
Arthritis
Other
None of the above
What type of materiel do you cook in? (Check All That Apply)
(Required)
Stainless Steel
Teflon Coated
Non-stick
Aluminum
Hard-Anodized Aluminum
Cast Iron
Glass
Porcelain
Copper
Enameled Cast Iron
Stoneware
Ceramic Non- Stick
Other
Pretend you’re a caterer who wants to satisfy 3 couples who ENJOY & EAT ALL menu items, & still make a profit. What amount of each item would you use? No answer is right or wrong, so trust your gut instinct! Please select number 0-10.
DON'T OVERTHINK IT! 3 Men & 3 Women are eating all menu items. Quantity of Food for ALL 6 Adults & Time Using a 4-burner stove.
How many Heads of Cabbage to Cut for Cole Slaw for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many Chicken Thighs for Fried Chicken for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many individual Med-Lg Russet Potatoes for enough Mashed Potatoes for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many heads of Med size head Cabbage to chop & cook as a side for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many 10" full length Carrots to Slice & Cook as a side for all 6 adults?
(Required)
Please enter a number from
1
to
12
.
How many 16 oz. bags of Frozen Peas to Cook as a side for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many 16 oz. bags of Frozen Corn to Cook as a side for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many Cake Mix boxes to Bake & Frost a Cake for all 6 adults?
(Required)
Please enter a number from
1
to
10
.
How many total cups of Oil (Include oil for frying Chicken Plus 1/2 C oil per box of cakemix)?
(Required)
Please enter a number from
1
to
10
.
How many Hours to cut/prep/fry/cook/mix/bake/frost all 8 items without help?
(Required)
Please enter a number from
1
to
12
.
Any Other Questions or Concerns?
These answers are private and never shared.
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