Ms. Leslie Johnson
Maplewood, NJ 07040

973-761-5218
973-761-5228 (fax)
   
  tpchef@ThePersonalChef.net
   

1. How did you hear about the personal chef?

 
2. What are your immediate needs? Check all that apply.

Just had a baby
Health Concerns
Hate to Cook
Want to Eat Healthier
Medically Supervised Diet
Don't Have Time to Cook
Weight Loss
 
3. What are you food preferences? Low fat, vegetarian, kosher, etc.
4. What are your family's weekly eating habits? How many nights a week do you
 Cook at Home
 Eat Out
 Get Delivery
   

5. How would you rate the current nutritional value of your meals on a scale of 1-5? 1 2345
 

6. Would you like to receive periodic informational e-mails from The Personal Chef?  Yes  No
   
   
Full Name
Phone
Address
E-mail
# of family members
Additional Questions