Name: Address:

Town: Phone Number:

Other Phone: E-mail Address:
1. Do you have any food sensitivities or allergies? Please list all.
a. If you do have food allergies, could your allergy result in anaphylactic shock?
 Yes No
b. If your food allergy is severe , do you carry an Epi Pen Yes No
c. Do you have any other allergies such as to dust, animals etc. Please list all.
2. Please list any foods or ingredients you do not like:
3. Do you have any special dietary requirements? Yes If yes, please explain No
4. What are some of your favourite dishes or meals?
5. Are you a Vegetarian? Yes No

6. If you are not a vegetarian, how do you prefer your steak to be cooked?
 Blue Rare Medium Rare Medium Well Well Done
7. What kind of spice scale do you prefer. 1 = not very hot at all OR 6 = being "on fire!"
1 2 3 4 5 6

8. What is your wine preference? Red White No wine
9. Do you have any other comments you would like to include?

Thank you for taking the time to fill out this questionnaire!