Hi there!

This questionnaire aims to understand who you are, what condition you are suffering from, your treatment, & your preferences to be able to build a customized nutritional plan to empower your fight.

What we do is combine your health information with the latest scientific nutritional research to best suit your needs.

First, what is your zip code?

We are currently serving NJ and NY ONLY.

We are sorry!

We are not delivering yet in your area but we will soon!

Leave your email address to be updated as soon as we do!

Are you a ...?

From now on, we will ask you to answer the following questions as if you were the patient.
Thank you!

Patient
Caregiver
Family/friend
Other

Great!

What is your name?

Hi {! answers.name !}!

Hi!

What is your gender?

Male
Female

How old are you?

Approximate Height

Approximate Weight

About how frequently do you exercise?

Not at all
Once or twice a month
Once or twice a week
Three or more times a week

Which condition are/were you/your friend suffering from?

Colon Cancer
Breast Cancer
Prostate Cancer
Lung Cancer
Skin Cancer
Leukemia
Lymphoma
Brain Tumor
Pancreatic cancer
Head & Neck Cancer
Ovarian Cancer
Other type of cancer

We are sorry!

At this time we cannot accommodate other conditions. Please inform us which one you're suffering from and we'll let you know as soon as we can help you!

Please also leave your email address so we can reach you then.

What are you hoping to achieve with Kindly?

I am a cancer survivor
Feel better
Regain weight after treatment
Empower my fight against the disease
Generally eat healthier
Other

Are you aware of the stage of the disease?

Just diagnosed
Stage I
Stage II
Stage III
Stage IV
I don't know

Have you already had any surgery related to your cancer?

Yes
No

Was this surgery any of the following?

Colon
Ilium
Stomach
Whipple (pancreas)
Esophagectomy
None of the above

Did you undergo any radiation treatment in the last 3 months?

YES
NO
I don't know

Was this radiation related to any of the following?

Colorectal
Head/Neck
None of the above

We are sorry!

At this time we cannot cater our meals to patients who have had these specific kinds of treaments.

Leave your email address to be updated when we can!

Are you going to follow any chemotherapy treatment in the next 8 weeks?

Yes
No
I don't know

Please enter your upcoming treatment dates.

Do your chemotherapy treatments include any of the following drugs?

You can select more than one if undergoing combination therapy

Gemcitabine
Cisplatin
5-Flurouracil
Docetaxel
Melphalan
Vincristine
Etoposide
Mitoxantrone
Topotecan
Irinotecan
Cyclophosphamide
Camptothecan
Mechlorethamine
Doxorubicin
Tamoxifen
Mitomycin C
Erlotinib
Bortezomib
Paclitaxel
Other
Not sure

Are you suffering from any of these other conditions?

Diabete
Hypertension
Cardiovascular Disease
Other
None

Please list any related medications you are currently taking.

It is important that you write down all the drugs as some may interact with food and supplements.

Please list any supplements you are currently taking on a recurring basis.

It is important that you write down all the supplements as some may interact with certain food.

Are you currently experiencing any of the following symptoms?

Constipation
Cough (dry)
Cough (wet - muscous based)
Diarrhea
Difficulty chewing
Difficulty swallowing
Dry mouth
Dry skin
Fatigue
Inflammation
Loss of appetite
Loss or change of taste
Mouth or Throat Sore
Nausea
Stomach Acidity
Trouble sleeping
Weight Loss
Weight Gain

Can you evaluate your following symptoms for us?

We need to understand the scale of pain of each symptom you're suffering from.
Scale of 1 to 5, 1= OK, 5= Worst pain.

Constipation

1
2
3
4
5

Dry Cough

1
2
3
4
5

Wet Cough

1
2
3
4
5

Diarrhea

1
2
3
4
5

Do you have any food allergies apart from dairy?

Yes
No

Dairy is not considered here since we don't do any dairy.

Our apologies!

Specific food allergies outside of dairy can't be accommodated for at the moment.

Please leave your email, and we will reach out once they are supported by our team.

Do you have any food restrictions?

Dairy is never part of our recipes.

VEGAN
Vegetarian
Pescatarian
None of the above

Have you been advised by a physician to follow a low fiber medical nutrition diet?

If you have been advised a maximum amount of fiber a day, we need to be aware of it.

< 12 g/day
< 18 g/day
< 25 g/day
< 30 g/day
No restrictions

We are sorry!

We cannot accommodate less than 18 g of fibers a day since our meals are whole food plant-based.

Leave your email address to be updated when we can!

Have you been advised by a physician to follow a soft food medical nutrition diet?

If yes, did they specify the of consistency of liquids and foods allowed?

Only Liquids
Puree Food Consistency (pudding consistency)
Ground Food Consistency (cottage cheese consistency)
Cut Up Food Consistency (1/4 - 1/2 inches pieces)
No restrictions (Whole Food Consistency)

We are sorry!

We unfortunately can not accommodate fully liquid or puree diets at this time.

Leave your email address to be updated when we can!

Please let us know if you have been advised by your physician to follow any other specific dietary restrictions.

Thank you for all this information!

What's your email?

All set!

We have all the information we need to be able to personalize the right nutrition to strengthen your immunity.

What's next?

1. Define your meal delivery plans.
2. Select your subscription level.

Are other members of the household interested in enjoying our meals?

YES
NO

How many other people will enjoy our meals?

People


Awesome! When do you want to start receiving your meals?

Meals are delivered once a week on a Monday.

Next Monday Available: {! nextMonday() !}

Subscriptions can be paused or cancelled at any time.

Regarding the number of meals...

Currently our plan will provide you with 21 optimized meals for you to enjoy every week.

Kindly will look to offer additional different options for the number of meals in the future. How many meals would you prefer a week?

How many breakfasts a week
How many lunches a week
How many dinners a week


This will help us understand how we can serve you better. Thank you!

All set! Our expert team will be in touch with you soon!

Please leave us a note if you have any other information we should know.