Lifestyle & Food Preferences · R.E.S.T.O.R.E. MNT

Step 1 of 11

About You

First Name

Last Initial

Age

Date Completed

Who is completing this form?

Referring Provider / Dietitian

Step 2 of 11

Food Allergies & Intolerances

Tap everything that applies. These will be flagged in your meal plan.

Common Allergies (IgE-Mediated)

Intolerances / Sensitivities

Other allergies or intolerances not listed:

Describe your reactions:

Step 3 of 11

Dietary Pattern at Home

Select the pattern that best describes how you currently eat. You may select more than one if applicable.

Standard Patterns

Gluten / Wheat

Dairy / Lactose

Plant-Based & Vegetarian Spectrum

Religious / Cultural

Currently following no set pattern

Other — describe your eating pattern:

Special diet followed at home

Step 4 of 11

Daily Rhythm

The shape of your day — when you wake, when you sleep, and how much time you realistically have to put food together.

Typical weekday wake time

Typical weekday bedtime

Weekend sleep pattern

Realistically, how much time do you have to prepare each meal?

Anything else about your daily rhythm we should know?

Step 5 of 11

Food Likes & Dislikes

In your own words, what foods do you genuinely enjoy, and what foods do you prefer to avoid?

Foods I like

Foods I dislike

Favorite brands

Step 6 of 11 — How often you eat these foods

Daily

Weekly

Monthly

Never

For each food listed below, tap how often you typically eat it, or tap Never if you don't eat it at all. Use the "+ Add other" field in each category to include foods you eat that aren't listed.

🥩 Proteins 18 items

FoodDailyWeeklyMonthlyNever

🥛 Dairy 9 items

FoodDailyWeeklyMonthlyNever

🍞 Grains & Starches 18 items

FoodDailyWeeklyMonthlyNever

🥦 Vegetables 23 items

FoodDailyWeeklyMonthlyNever

🍎 Fruits 25 items

FoodDailyWeeklyMonthlyNever

🥒 Fermented Foods 8 items

FoodDailyWeeklyMonthlyNever

🫒 Fats & Condiments 13 items

FoodDailyWeeklyMonthlyNever

🌶 Sauces & Dips 13 items

FoodDailyWeeklyMonthlyNever

🍪 Snacks & Desserts 14 items

FoodDailyWeeklyMonthlyNever

🧃 Beverages 15 items

FoodDailyWeeklyMonthlyNever

Favorites & Go-Tos

No judgment here — just an honest picture of what you actually eat. Everyone has favorites and comfort foods. Especially helpful if you're filling this out for (or with) a child or teen.

🍕 Favorite Meals 7 items

FoodDailyWeeklyMonthlyNever

🥨 Favorite Snacks & Go-Tos 11 items

FoodDailyWeeklyMonthlyNever

Step 7 of 11

Typical Day of Eating

Think about what a usual day looks like. Fill in approximate times and what you typically eat. Leave blank any meal or snack you don't usually have.

Weekday

Meal 1

Meal 2

Meal 3

Meal 4

Snack 1

Snack 2

Snack 3

Snack 4

Weekend

Meal 1

Meal 2

Meal 3

Meal 4

Snack 1

Snack 2

Snack 3

Snack 4

Step 8 of 11

Kitchen Inventory

What’s typically in your kitchen right now. No judgment — an honest picture of what’s there, so the meal plan fits what you already have.

🏠 Pantry — typical contents (tap all that apply)

❄️ Fridge — typical contents (tap all that apply)

☃️ Freezer — typical contents (tap all that apply)

🔧 Kitchen equipment — what you have access to (tap all that apply)

This tells us what recipes and meal prep methods actually work for your setup. No judgment — an honest picture helps your meal plan fit your reality.

What do you always keep stocked?

What do you rarely have at home?

Anything else about your kitchen we should know?

Step 9 of 11

Seasonings, Condiments & Shopping

Help us understand your pantry staples, preferred flavors, and where you shop.

Preferred seasonings

Preferred condiments

Sugar — do you use it? (type & amount)

Sugar substitute (type & amount)

Honey (how & how often)

Nutella (how & how often)

Salad dressing (type & brand)

Coffee creamer (brand & type)

Forms of food you consume — tap all that apply

Leftovers — do you eat them?

Who prepares meals?

Breakfast

Lunch

Dinner

Snacks

How do you portion foods? — tap all that apply

Who does the grocery shopping?

Shopping method — tap all that apply

Where do you shop? (specific stores)

Step 10 of 11

Favorite Places & Cuisine

Where you love to go and the flavors you reach for.

Favorite restaurants

Favorite coffee shops

Favorite sweet treat / dessert shops

Favorite social eating spots

Favorite quick / fast food places

Favorite beverages

Cuisine preferences — tap all that apply

Other cuisines you enjoy

Step 11 of 11

Foods & Textures I Find Difficult

Some people have foods they genuinely struggle to eat — because of taste, texture, smell, appearance, or past experiences. This section helps us understand what feels hard and why. Share as much or as little as is helpful; there's nothing here you have to fill in.

Food textures I find difficult — tap all that apply

Other textures or sensory things that are hard

Foods I have a hard time with — and why

Foods I avoid — and the reasons why

Final Notes

Anything Else?

Is there anything about your eating or food preferences we haven't covered that would help us build a plan that feels natural for you?