I.   Restaurant Information:

Restaurant Street Address:(required)          Restaurant City:(required)            Restaurant Zip:(required)
        

2nd Restaurant Street Address:                  2nd Restaurant City:                     2nd Restaurant Zip:
        

Contact Person:(required)                         Phone (xxx) xxx-xxxx:(required)    Extension:
        

Business Email:

Restaurant Website:

 

II.  Please mark Yes or No to each of the following questions:

Healthy food preparation (baked, grilled, broiled) for our patrons
Yes  No

Announcements to patrons or has indicators on the menu noting the availability of lower fat substitutes for salad dressings or sauces,  or heart healthy entrées
Yes  No

III.  Please check any of the items listed below that are currently on your menu:

Dairy: 
    Skim milk, and/or
    1% milk, and/or
    Light fat-free yogurt

    Breads: Whole grain or multigrain bread 

    Salad Dressings: Fat-free, vinaigrette, or light salad dressings 

    Fresh Fruit: offered with meals or as a side dish

    Vegetables: include steamed broccoli, cauliflower, carrots, green beans or any
          vegetable other than corn or potatoes

    Meats: baked, grilled, or broiled lean cuts of beef, chicken, turkey, or fish 

IV.   Menu Options: Please check options and/or changes your restaurant would consider in order to make
          your current menus healthier for patrons

    Substitute salad or vegetables for french fries or chips on sandwich plates.

    Prepare any meat, fish, poultry, eggs without significant fat added (non-stick cooking spray is ok)

    Serve sauces and dressings on the side

    Omit cheese and croutons from salads/soups

    Omit butter or oils when grilling bread for sandwiches

    Offer mayonnaise or other high-fat sauces on sandwiches as a “request only”

   Reduce patron’s portion size by:

    Splitting entrées-(price negotiable)

    Offer smaller (lunch) portions for some items at all times, and/or

    Place half of entrée in carry out container at any time during the meal

B.  Options for Breakfast and Children’s Menus:

     If Breakfast is served, your restaurant would be willing to offer:

    egg-beaters or similar egg substitute for egg-based meals

    use of non-stick spray when preparing eggs, pancakes, or French toast

    at least one Fresh Fruit as an alternative for potatoes, grits or bread

    lite syrup for pancakes/French toast.

    toppings for pancakes/ French toast on the side

    whole grain bread for toast/French toast

    at least one unsweetened whole grain cereal such as Cheerios, Wheaties, bran flakes

    100% vegetable or fruit juice

    If a children’s menu is available, your restaurant would be willing to offer:

    a small ham or turkey sandwich on bread of choice as an alternative to fried foods

    substitute a fruit, vegetable and/or salad for fries/chips

    milk (1% or skim) or 100 % juice can be substituted for “included” beverage

When you have completed the Survey, please click on the "Submit the Survey" button below. Healthy Volusia will notify you if your submissions meets the Criteria for the Healthy Volusia Seal. Please call Tonia Marchena at (386) 274-0682 if you have any questions reguarding this survey or would like to receive healthier food options information.