FREE & Confidential Personal Nutrition Analysis
start
 
Your Name *

 
Your Age

 
Your email *

 
Your cell phone number *

Why do I need your cell phone number? Because email filters may send an email for your assessment follow up to your spam or promotional mail and you won't see it.
 
Your current weight: *

 
Your height: *

 
Primary Concerns:

How much weight would you like to lose? *

 
How many years have you struggled to lose weight? *

 
I have a family history of *


 
I live with *


 
I have been diagnosed with ...

 
I would like to reduce or eliminate these medications:

 
Training, endurance and overall health are a primary concern. *

     
 
My other primary health concerns are:

 
Diet Profile:

How many alcoholic drinks (wine, beer or liquor) do you have a week? *

 
How many times a week do you consume baked goods, desserts, sweet treats including fancy coffee drinks? *

 
How many times a week do you consume restaurant meals or takeout from a deli or grocery store or restaurant? *

 
How many times a week do you consume home cooked meals that are made from scratch (not frozen meals or prepared food from the grocery)? *

 
How many times a week do you consume red meat, processed meat, lunch meat, fried foods of any kind? *

 
How many times a day do you consume greens? *

 
How many times a day do you consume other vegetables? *

 
How many times a day do you consume fruit? *

 
How many times a day do you consume soda (including diet) & bottled beverages other than plain water, seltzer, plain tea? *

 
How many times a day do you consume baked goods, desserts, sweet treats including fancy coffee drinks? *

 
How many times a day do you consume salty snacks (chips, pretzels)? *

 
How many times a day do you consume processed grains: bread, pasta, white rice, crackers, granola bars ? THIS INCLUDES GLUTEN FREE PRODUCTS *

 
How many times a day do you consume non-processed whole grains (eg: oats, corn, quinoa, brown rice, kamut, spelt, millet) ? *

 
How many times a day do you consume protein bars, and is that as a meal replacement or in addition to meals (such as a snack before or after exercise)? *

 
How many times a day do you consume protein shakes or smoothies, and is that as a meal replacement or in addition to meals (such as a snack before or after exercise?) *

 
How many snacks to do you consume a day and what do you eat? *

 
My meals are 50% vegetables or (breakfast) fruit


 
When I eat out I control portions and choices *


 
People around me support my healthy eating efforts *


 
Please identify all of the habits you struggle with *


 
If you currently work with an Action fitness trainer and you choose to work with an Action nutrition coach, would you be willing to have your nutrition coach and trainer share information to help you reach your goals?

     
 
Would you like to receive my email newsletter with nutrition information and links to my blog posts about healthy eating? *

If you select yes, once I add you - you will receive an email from me - Nancy Popkin, nancy@lovemoreeatless.com, that will require you to confirm that you would like to receive it.
     
 
Thank you for completing your free nutrition analysis. When you press "enter" your answers will be sent directly to our Director of Nutrition, Nancy Popkin. She will be in touch to go over the score of your nutrition analysis.

Thanks for completing this typeform
Now create your own — it's free, easy & beautiful
Create a <strong>typeform</strong>
Powered by Typeform