Rosie's Plate Survey
1.
How may people in your household have food restrictions?
1
2-3
4 or more
2.
Check age groups of the people in your household with food restrictions. Check all that apply.
Under 5
5-17
18-25
26-65
Over 65
3.
What foods are you, or others in your household, restricted from eating? Check all that apply.
Gluten
Cow Milk Dairy
Goat Milk Dairy
Eggs
Egg Whites
Egg Yolks
Peanuts
Tree Nuts
Shell Fish
Fish
Shrimp
Soy
Corn
Meat
Sugar
Salt
4.
If Rosie's Plate could provide you with one food you have been missing, what would it be?
 

  • 500 character(s) left.
5.
Would you be interested in the following classes?
Cooking for Restricted Diet
Meal Planning
Nutrition
Foods That Heal
Other  
6.
When would be the best time to attend these classes?
Weekdays
Weeknights
Saturdays
Sundays
7.
Do you have any other comments or suggestions?
 

  • 500 character(s) left.
8.
Please give us your name, address and email address for our mailing list.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

9.
How did you find out about Rosie's Plate?
News & Observer
Independent Weekly
Carolina Parent
Natural Awakenings
Health & Healing
A Friend
Other