Nutrition Plan Design Questionnaire

Thank you for choosing Ben’s Coaching Program for your nutrition plan design! This questionnaire will allow thorough development of a personalized nutrition plan for you. Take your time answering these questions so that your customized plan will be as beneficial as possible. After you have completed the form, please remember to click the “Submit” button at the bottom of this page.

Contact Details
Name*
First Last
Age*
Birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Gender*
- Male
- Female
Height*
Weight (lbs)*
Waist Circumference (in)*
Wrist Circumference (in)*
Hip Circumference (in)*
Forearm Circumference (in)*
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Today's Date (please input date as mm/dd/yyyy)*
MM slash DD slash YYYY
Lifestyle
Describe your job.*
Do you consider your job physically challenging or active?*
How many hours per day 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.*
- 1 - No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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
What time do you usually go to bed at night and wake up in the morning?*
Do you have an exercise regimen? Please describe as specifically as possible. Include the activities, days/times, intensity and duration/volume.*
Are there any other notes about your lifestyle that you would like to share?*
Health History
If you answer "yes" to any of these questions, please provide details such as date of occurrence, frequency, intensity, amount, etc.
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.
Are you postmenopausal?
- 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 including nutritional 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?*
Do you have any medical issues that have not yet been discussed in this questionnaire?*
- Yes
- No
Please give details.
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 - 1.5 (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? If yes, please explain.*
Please describe any religious, ethical, or logistical limitations regarding nutrition:*
Use the following section to include any additional nutritional notes:
Final Thoughts
Describe what you truly desire from optimizing your nutrition. What do you want to achieve? 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!
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 Coaching, 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 recommendations from Ben Greenfield and his affiliated coaches are merely a suggestion and not a prescription.
Acknowledgment*
- I understand I will receive a food plan, food list, and supplementation suggestions along with 1-year access to a food tracking and recipe platform. If I desire additional accountability and extended follow-up from my coach, I will opt for the nutritional accountability package in addition to this plan. I agree to the no-refund policy and understand the immense amount of time and effort it takes for my coach to put this plan together.
Please type full name here:*

Nutrition Plan Design Questionnaire

Contact Details

Lifestyle

Health History

Nutrition & Metabolism

Final Thoughts

Activity Waiver