75% 100% 50% 0% 25% time Initial Follow- up time the applicable Consider ( C) Consider( C) Never the of Rarely Not Doing ( D ) Doing ( D ) of Sometimes No ( N ) No ( N ) Comments: Most All Date: Response # 1 2 3 4 5 99 Date: Date: To what extent Would the does the restaurant restaurant? consider? Comments By request Example: half sandwich or Offer smaller or available salad and cup of soup, 4 oz. 1 portion sizes? on menu? steak, etc. Offer fruit or Exclude *Coleslaw- ask about the vegetables as a base- mayonnaise or 2 side dish? salads vinegar? Offer substitution of salad or other At an vegetable for additional french fries or charge? 3 chips? Yes No Serve salad Encourage the restaurant dressing on the How many owner to always serve salad 4 side? request? % dressing on the side Use cheese as an option for an entrée or sandwich as opposed to an Is there an automatic extra 5 ingredient? charge? Use bacon as an option for an entrée or sandwich as opposed to an Is there an automatic extra 6 ingredient? charge? Column total 0 0 0 0 0 0 Notes: Ask for a copy of the menu. How many types of soup are prepared in total? How many types of soup are offered daily? Number of entrees on the menu, including breakfast, lunch and dinner (no duplication): Number of side dishes on the menu, including breakfast, lunch and dinner (no duplication): Do not count Not Applicable points in Score. Each Not Applicable items will = 5 points when you enter it on the final scorecard
Never 0% Rarely 25% Sometimes 50% Most of the time 75% All of the time 100% Not applicable Initial Consider ( C) Doing ( D ) No ( N ) Follow- up Consider( C) Doing ( D ) No ( N ) Comments: Date: Response # 1 2 3 4 5 99 Date: Date: To what extent does the restaurant? Would the restaurant consider? Comments 1 Offer smaller portion sizes? By request or available on menu? Example: half sandwich or salad and cup of soup, 4 oz. steak, etc. 2 Offer fruit or vegetables as a side dish? Exclude salads *Coleslaw- ask about the base- mayonnaise or vinegar? 3 Offer substitution of salad or other vegetable for french fries or chips? At an additional charge? Yes No 4 Serve salad dressing on the side? How many request? % Encourage the restaurant owner to always serve salad dressing on the side 5 Use cheese as an option for an entrée or sandwich as opposed to an automatic ingredient? Is there an extra charge? 6 Use bacon as an option for an entrée or sandwich as opposed to an automatic ingredient? Is there an extra charge? Column total 0 0 0 0 0 0 Notes: Ask for a copy of the menu. How many types of soup are prepared in total? How many types of soup are offered daily? Number of entrees on the menu, including breakfast, lunch and dinner (no duplication): Number of side dishes on the menu, including breakfast, lunch and dinner (no duplication): Do not count Not Applicable points in Score. Each Not Applicable items will = 5 points when you enter it on the final scorecard