Wholesome Nourishment Portland

New client intake

Tell me who I am cooking for and what their body needs. This takes about five minutes. A family member or caregiver can fill it out on the client's behalf.

Who this is for

Client name *

Age (optional)

Who is filling this out? *

The client Family member Caregiver Case manager

Best contact name *

Phone *

Email *

Delivery

Delivery address *

City *

ZIP *

Access notes

Preferred delivery day

Service and portions

Which plan is this for? *

Weekly meal prepFresh heat-and-eat meals delivered each week Monthly freezer stockOne bulk delivery of frozen labeled meals per month Recovery packageShort-term meals after surgery, hospital stay, or illness Not sure yet, help me choose

How many people eating?

Meals per week

Portion size

Eating type

Pick the one that fits best.

Eats everything PescatarianFish, no other meat Vegetarian Vegan

Other eating style

Medical and therapeutic diets

Check anything the client needs. These change how meals are cooked and seasoned.

Other diet orders

Allergies

Check any that apply, then add details below.

Allergy details and severity

Likes and dislikes

Favorite foods and meals

Foods to avoid or dislikes

Spice level

Health and coordination

Helps me cook for where the client is right now. Skip anything that does not apply.

Current situation

Who should I coordinate with?

Anything else I should know

Wholesome Nourishment Portland · (404) 232-0556 · wholesomenourishmentportland@gmail.com