Intake Form

These answers are private and never shared.

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TIPS & INSTRUCTIONS FOR SUCCESSFUL SUBMISSION 1) Answers for each field go BELOW the question (not above). 2) If submission fails, look for highlighted red areas where answers were missed. 3) Menu numbers must be at least 1 since all 6 adults want to fully partake of all menu items. 4) Number must be an exact digit (Not a range or in word form) 6) Show Mixed numbers as a decimal (ie 1.5) 7) Special notes can be typed in the last field. Thank you!

Name(s) of Individual or Both Spouses/Mates(Required)

First Last

Name of Dr., friend, or event who referred you?(Required)

First Last

Date and Time of your scheduled HealThy Cooking experience?(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Are you Married? or have a Partner?(Required)

Yes

Do you cook together?(Required)

Yes

Choose one. (Note: Fun & educational, so focus matters)(Required)

Date Night (Adults only)

Parents with children (If chosen, try to have minimal distractions for focus))

Unmarried

How many adult and child-size eaters will we be cooking for?(Required)

Do you enjoy cooking?(Required)

Yes

Sometimes

Which of the following meal plan do you use?(Required)

Variety to include meat, chicken, fish, & vegetables

Pescatarian

Vegetarian

Plant Based/Vegan

List any foods that you are allergic to or cannot eat

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.

Which 2 or 3 are most important to you when planning Daily Meals?(Required)

Healthy Meal

Cook in less time

Save Money on meals

Flavor of the meal

Clean-up of the meal

What is your main health goal in your family?(Required)

Does anyone in your household suffer from any of the following symptoms? (Check All That Apply) (These can be associated with Heavy Metal Toxicity)(Required)

Nervous System Disorders

Immune Dysfunction

Depression

Digestive Issues

Fatigue

Muscle Weakness

Achy Joints

Anemia

Memory Loss

Headaches

Arthritis

Other

None of the above

Please check family history (include immediate family, both parents & their siblings & all grandparents)(Required)

High Cholesterol

Digestive Disorders

High Blood Pressure

Cancer

Dementia / Alzheimer’s

Diabetes

Leaky Gut

Autism/ADHD/ADD

None of the above

Do you & your family try to maintain nutrition & eliminate unhealthy fats when cooking?(Required)

Yes

Does anyone in your household suffer from indigestion, gas or tiredness after eating?(Required)

Yes

Does anyone in your household have inflammation?(Required)

Yes

Does anyone in your household have a health concern?(Required)

Yes

If yes, what is it?(Required)

Does anyone in your household have brain fog?(Required)

Yes

Does anyone in your family have a chronic disease?(Required)

Yes

Do you find it difficult to get your family/children to eat healthy?(Required)

Yes

How many portions of fruit and vegetables does your family 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.

Would it help to know a method of food preparation that cuts your kitchen time in half & without compromising nutritional value?(Required)

Yes

Maybe

How much do you spend weekly on groceries?(Required)

How much do you spend monthly eating meals from a restaurant?(Required)

Have you heard of any health concerns about different cooking material?(Required)

Yes

What type of material 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

Microwave

Air Fryer

Pressure Cooker/Instapot

Crockpot

Other

Pretend you’re cooking the following 8-item meal for 3 men and their 3 wives, assuming they requested this as everyone's favorite meal. How much of each item would you use to satisfy all 6 without excess waste, and how many hours to chop up, cook, fry and bake all 8 items using only 4 burners without any help. DON'T OVERTHINK IT! No answer is right or wrong, so trust your gut instinct! Please select number 1-10. May use decimals (i.e., 1.5)

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.

Schedule Your Complimentary Virtual or Live HealThy Cooking Session
(214) 592-9972

3440 Eldorado Pkwy #4 McKinney, TX 75070
Recipe Nights Restart October 14th 2025

Section Break

Schedule Your Complimentary Virtual or Live HealThy Cooking Session (214) 592-9972

3440 Eldorado Pkwy #4 McKinney, TX 75070 Recipe Nights Restart October 14th 2025

Intake Form

Section Break

Schedule Your Complimentary Virtual or Live HealThy Cooking Session
(214) 592-9972

3440 Eldorado Pkwy #4 McKinney, TX 75070
Recipe Nights Restart October 14th 2025