Your Visit Date:
Server Name:
Frequency of Visits First time visit Visit less than once a month Visit more than once a month

1 = Terrible 2 = Poor 3 = Fair 4 = Good 5 = Excellent 6 = WOW!

Menu Readability 1 2 3 4 5 6
Quality of Food 1 2 3 4 5 6
Temperature of Food 1 2 3 4 5 6
Size of Portion 1 2 3 4 5 6
Friendliness of Server 1 2 3 4 5 6
Appearance of Server 1 2 3 4 5 6
Cleanliness of Dining Area 1 2 3 4 5 6
Cleanliness of Restroom 1 2 3 4 5 6
Overall Value 1 2 3 4 5 6

Would you recommend this Restaurant Yes No

If there is one thing we can do to improve your visit next time, it is

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