New Client Questionnaire

Please complete the following form as a new client.

Congratulations on choosing to optimize your body and health through a Ben Greenfield coaching plan. Your coach will customize your entire program, but first, we must assess your goals and current level of health and fitness through the questionnaire below. Please complete it with the greatest detail possible to allow for personalization at the highest level.

A Coach Liasion will contact you within 48 hours after completion of this form to schedule a meeting. Please remember to push the “submit” button at the bottom of this page.

Your Contact Details
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Male
- Female
Age*
Birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Height*
Weight (in lbs)*
Waist Circumference (in)*
Wrist Circumference (in)*
Hip Circumference (in)*
Forearm Circumference (in)*
Today's Date (mm/dd/yyy)*
MM slash DD slash YYYY
Your Lifestyle
Describe your job.
Do you consider your job physically challenging or active?
How many hours do you spend in front of a computer?
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career.*
Hidden
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career.
- 1 - No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - A lot of stress
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life.*
Hidden
On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life.
- 1 - No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - A lot of stress
What time do you usually go to bed at night and wake up in the morning?
Are there any other notes about your lifestyle that you would like to share?
Important Questions About Your Health History
Do you suffer from back pain?*
- Yes
- No
Please give details.*
Are you sensitive to touch/pressure in any area?*
- Yes
- No
Please give details.*
Do you have tension, numbness or pain in a specific area?*
- Yes
- No
Please give details.*
Do you experience frequent headaches?*
- Yes
- No
Please give details.*
Are you pregnant?*
- Yes
- No
Please give details.*
Have you ever given birth?*
- Yes
- No
Please give details*
Do you have high blood pressure?*
- Yes
- No
Please give details.*
Do you have high cholesterol?*
- Yes
- No
Please give details.*
Have you ever had surgery?*
- Yes
- No
Please give details.*
Have you ever broken any bones?*
- Yes
- No
Please give details.*
Do you experience stiff, swollen or painful joints?*
- Yes
- No
Please give details.*
Do you have difficulty sleeping?*
- Yes
- No
Please give details.*
Do you experience fatigue or lack of energy?*
- Yes
- No
Please give details.
Do you experience cold hands or feet?*
- Yes
- No
Please give details.*
Have you ever been advised by a physician to avoid any type of exercise?*
- Yes
- No
Please give details.*
Have you ever been knocked unconscious or suffered a concussion?*
- Yes
- No
Please give details.*
Do you (or does someone in your family) have a cardiac condition?*
- Yes
- No
Please give details.*
Do you have any known allergies?*
- Yes
- No
Please give details.*
Are you currently taking any medications (not nutrition supplements)?*
- Yes
- No
Please give details.
Do you smoke or have you smoked in the past?*
- Yes
- No
Please give details.*
Have you ever been tested positive of COVID?*
- Yes
- No
When? Please give details*
Have you had COVID vaccine shot(s)?*
- Yes
- No
When and which brand?*
Are there any medical issues which have not been discussed on previous questions?*
- Yes
- No
Please give details.*
Your Exercise Status
Describe your current exercise routine, if any.
List down any fitness tools, equipment, technology or gears that you own or have access to.
What is the heaviest you have weighed, and how old were you at that time?
What previous fat loss, lean muscle gain, or body improvement treatment(s) have you tried? Please state what and when.
Have you ever had any of the following: physical therapy, chiropractic, massage, acupuncture, Feldenkrais, rolfing, Alexander technique, Other? Please elaborate.
Have you ever worked with a personal trainer? If so, provide details:
How many days do you have to commit towards exercise (include the approximate number of minutes)?
Are there any areas of your body that you consider “problem areas”?
Your Nutrition & Metabolism
Have you ever had your metabolism tested?*
- Yes
- No
Please give details.*
Do you count or track calories?*
- Yes
- No
Please give details.
Does a high carb snack or meal, with lots of veggies, bread, toast, cereals, rice, fruits, grains or potatoes as the main food source satisfy or stimulate your appetite?
- 1 - satisifies
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - stimulates
Do you notice that you gain a lot of weight when you eat red meat, or lose weight? Do you look slimmer in the mirror or do your clothes fit easier?
- 1 - gain weight
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - lose weight
Do you constantly look forward to the next meal, frequently thinking about foods and what you want to eat?
- 1 - yes
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - no
What is your appetite like at breakfast?
- 1 - weaker
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - stronger
What is your appetite like at lunch?
- 1 - weaker
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - stronger
What is your appetite like at dinner?
- 1 - weaker
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - stronger
Do higher fat foods and/or higher protein foods such as dark meats, avocados, cream, butter, or coconuts within 1-2 hours of bedtime help you sleep better?
- 1 - yes
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - no
If you ate a large salad with some low-fat meat like chicken breast for lunch (versus a higher fat meat like a hamburger patty), how would it affect your productivity the rest of the afternoon?
- 1 - energetic and satisfied
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - tired and hungry
What about if you ate a steak?
- 1 - energetic and satisfied
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - tired and hungry
How often do you typically feel the need to eat on an average day? One meal would be a 1, three meals a day would be a 5, while six to seven meals a day would be a 10.
- 1 - 1-2x including snacks
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - 6-7x including snacks
How much do you enjoy sour foods like pickles, sauerkraut, or vinegar?
- 1 - love them
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - can’t stand them
At Thanksgiving or a meal where you eat turkey, assuming all the turkey is moist, if you prefer white meat give yourself a 1, dark meat a 10, and no preference a 5.
- 1 - white meat
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - dark meat
What is a typical breakfast?
What is a typical lunch?
What is a typical dinner?
Describe your snacking habits in between breakfast, lunch, and dinner:
Describe your pre-workout nutritional habits, if any:
Describe your “during the workout” nutritional habits, if any:
Describe your post-workout or nutritional habits, if any:
Describe all nutritional supplements you are currently using. Include multi-vitamins, sport supplements, electrolytes, and any special juices, pills, capsules or tablets:
How much water do you drink per day, apart from exercise?
How much water do you drink during exercise?
Please describe any known food sensitivities, or intense likes/dislikes:
Do you ever have heartburn, gastrointestinal distress, or stomach problems?
Please describe any religious, ethical, or logistical limitations regarding nutrition:
Use the following section to include any additional nutritional notes:
Your Lifestyle
Your lifestyle, including work and family life, is an incredibly important component of your health success. Emotions, relationships, stress and organization of your day are crucial to the success of your program. No matter how good the exercise, nutrition or “biohacking regimen” is, you will not look, feel or perform the way you want to if your energy is drained by lifestyle patterns. The following questions will help Ben better understand your daily life and routine.
How would you describe your family, relationship and love life? Include details such as spouse, quality of relationship to him/her and his/her role in your life, including their career; children and your connection/relationship with them and your current social life and social habits.*
How would you describe a typical day or week of work for you? Include details about travel, meetings, work hours and the enjoyment you do or do not derive from different aspects of your career.*
Do you feel you have a stressful life? If so, what kind of stress management tactics do you currently employ?*
Do you have any spiritual disciplines, such as charity/service, meditation, gratitude or other journaling, prayer, religious practice or anything else you do to care for your spirit and soul?*
Is your day setup with routines, rituals or habits (e.g. not turning on phone first thing in morning, taking X number of steps per day, reading certain books at night, etc.). In other words, describe any staples or must-haves of your daily routine.*
Coach Matching
Do you have a preference for the gender of the coach you will be matched with?
- Male
- Female
- No preference
Coaching style
- I want to learn more about my body and the "why" behind recommendations
- I prefer simplicity and being told exactly what to do
Accountability
- I have a strong sense of self motivation and will easily implement recommendations on my own
- I will need follow-up and reminders to help keep me on track
Please describe any additional coaching preferences.
Your Final Thoughts
Your Goals
Describe what you truly desire from completing this program. What do you want to acheive? Out of your fitness? Out of life? What do you want your body to look like in 1 year? 5 years? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your specific goals or objectives? Be as honest and specific as possible, describing your dream body, lifestyle, or health. Pour yourself onto the page. Include anything that you feel would be helpful that you haven’t yet had a chance to express. All your responses remain completely confidential!
Thanks for taking the time. We can now use this information to help you reach your dreams.
Activity Waiver
Please read the following waiver, then if you agree to the terms, sign by typing your full name in the box below, and submit.

Activity: Any and all prescribed, instructed, implied or suggested activities from Ben Greenfield and Ben Greenfield Coaching, LLC (collectively referred to as “The Released Party”), and all volunteers, agents, employees or independent contractors in any way associated with the Released Party, including, but not limited to all multi-sport related physical activities, outdoor endurance running and sprinting, running, jogging, and walking at a moderate to high effort on a grass surface; muscular stretching and flexibility exercises; body weight and calisthenic exercises, including push-ups, sit-ups, squats and lunges; plyometric and jumping activities including straight up and side to side jumping on surface such as rubber, grass, and asphalt; suggested take home exercises; open water swimming (for triathletes and swim lessons), often at depths above head level; weightlifting; rowing; stair climbing; indoor bicycling; bicycling on and off roads that are open to traffic; dismounting from bicycle; tracking nutritional intake; increasing or decreasing caloric intake; suggested meal plans, menus, or recipes; food supplementation; or any other activity prescribed, instructed or suggested from Ben Greenfield and Ben Greenfield, LLC and not listed in this document.

RELEASE OF CLAIMS, ASSUMPTION OF RISK, CONTACT AND WAIVER OF LIABILITY

I understand and am aware that this Activity is potentially hazardous. I acknowledge the possibility that injuries and physical and mental changes arising during and/or resulting from engaging in this Activity do exist. These injuries and changes include, but are not limited to, abnormal blood pressure, fainting, disorders in heartbeat, heart attack, joint injuries, and, in some instances, death. I understand injuries and changes could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life. I am voluntarily participating in this Activity with knowledge of the dangers involved. I understand and take sole responsibility for any and all injuries and changes that may occur to myself and/or others, including but not limited to Ben Greenfield, Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors related to any and all Activities associated with Ben Greenfield and Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors even if not specifically set forth in this document, whether or not they fall within the scope of reasonably foreseeable injuries related to this Activity, and whether or not undertaken in the presence of staff or physical location of Ben Greenfield and Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors. Although Ben Greenfield, Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors will take precautions to ensure my safety, I expressly assume and accept sole responsibility for my safety and for any and all injuries and changes that may occur.

I release Ben Greenfield, Ben Greenfield Coaching, LLC, and all volunteers, agents, employees, or independent contractors in any way associated with the Released Party from any and all liability for any personal injury, death, property damage or loss I may suffer as a result of, arising from, related to or in any way connected to my participation in this Activity, and for any cause whatsoever including negligence, including active negligence, passive negligence or gross negligence on the part of Ben Greenfield, Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors in any way associated with the Released Party.

I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in this Activity. I acknowledge I have been informed of the need for a physician’s approval for my participation in an exercise/fitness Activity.

I recognize it is my sole responsibility to obtain an examination by a physician prior to involvement in any exercise program. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this Activity, I acknowledge I am doing so at my own risk.

I understand that if under any circumstances I experience lightheadedness, dizziness, muscular pain, excessive fatigue or any other painful or uncomfortable signs that exceed normal exercise fatigue, I am not obligated to continue this Activity.

Furthermore, I may stop this Activity at any time as I desire. Ben Greenfield and Ben Greenfield Coaching, LLC’s personal trainers, coaches, and sports nutritionists are not Physicians or Registered Dieticians. They do not diagnose or treat disease.

I have been informed that I should consult a Physician before undergoing any dietary or food supplement changes. Any recommendations or suggestions from Ben Greenfield, Ben Greenfield Coaching, LLC and all volunteers, agents, employees, or independent contractors for changes in my diet, including but not limited to the use of food supplements, food substitutions, caloric intake, meal plans, recipes, and menus are entirely my responsibility, and I release Ben Greenfield, Ben Greenfield Coaching, LLC and all volunteers, agents, employees or independent contractors from any and all liability for any illness, personal injury, death, property damage or loss I may suffer as a result of any change in my nutrition, diet, or food intake.

I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program. I understand results are individual and may vary.

This Waiver and Release shall be governed by the laws of the State of Washington. All disputes arising from this Waiver and Release Agreement, and participation in any Activity, whether in Contract, Tort or Equity, shall be brought in the State of Washington.

By signing below, I agree to subject myself to the jurisdiction of Washington and thereby waive any argument of lack of personal jurisdiction or forum non conveniens.

I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Ben Greenfield, Ben Greenfield Coaching, LLC and its respective representatives, executors, and/or assigns.

I confirm that I have read over this agreement before signing, that I understand it, and that it will be binding not only on me but also on my heirs, my next of kin, my executors, administrators and assigns.

I represent and warrant I am signing this agreement freely and willfully and not under fraud or duress.

I further represent and warrant no social relationship exists between Ben Greenfield and his affiliated coaches and me, or if such a social relationship exists, for purposes of my training sessions, Trainer and I have assumed a strict business relationship, and I understand any social relationship does not render this waiver invalid.

These exculpatory clauses are intended to apply to any and all activities occurring during the time for which I have contracted with Ben Greenfield and Ben Greenfield Coaching, LLC.
Agreement
- I have completely read, fully understand, and agree to this release of claims and waiver of liability. I also understand that any nutritional and exercise recommendations from Ben Greenfield and his affiliated coaches are merely a suggestion and not a prescription.
Please type full name here:*

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New Client Questionnaire

Please complete the following form as a new client.

Your Contact Details

Your Lifestyle

Important Questions About Your Health History

Your Exercise Status

Your Nutrition & Metabolism

Your Lifestyle

Coach Matching

Your Final Thoughts

Activity Waiver