I.   Restaurant Information:

Restaurant Name: (required)

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 entrees
Yes  No

We cater to the health conditions of our patrons and or allow them to customize their entrée choices
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
    Low fat or fat-free cheese

Breads: 
    Whole grain or multigrain breads
    Whole wheat pizza crust
    Soy Flour crust

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

    Fresh Fruit / Fruit cup: offered with meals or as a side dish

    Salads: Includes tossed, spinach, or vegetarian

    Meats: Use baked, grilled, or broiled lean cuts of beef, chicken, turkey (sausage, bacon or Pepperoni), or fish

    Pasta: Whole wheat pasta

    Sauces: Low fat or non fat: Marinara / Alfredo / Pesto / Buffalo

Other sides: 
    Baked and / or salt-free chips
    Skinless, baked chicken wings
  

IV.   Menu Options: Please review and check healthier options and / or changes your restaurant would consider making in the          current menus

    Substitute salad for chips on sandwich plates

    Prepare any meat, fish, poultry 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 and / or use in pizza crust

    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, 4-6" subs, or individual slices of a thin
         crust or vegetarian pizza

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

B.  Children’s Menus: - If a children's menu is available, your restaurant would be willing to offer:

    Small ham or turkey sandwich on whole wheat, multigrain, oat-bran, or rye bread as an alternative to white

    Individual serving of pasta or pizza to include whole grain option

    substitute a fruit, vegetarian salad or raw vegetable slices 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.