Training Plan Design Questionnaire - Ben Greenfield Coaching

Contact Details

Name*

First Last

Birthday (mm/dd/yyyy)*

Age*

Gender*

Male
Female

Are you an athlete intending to use this plan for race or competition training?*

Yes
No

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)*

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.*

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.*

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?

Health History

If you answer "yes" to any of these questions, please provide details such as date of occurrence, frequency, intensity, amount, etc.

Height*

Weight*

Body Mass Index (BMI)

Indicate any notes regarding height or weight issues.

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.

Exercise Status

Describe your current exercise routine, if any.*

What previous fat loss, lean muscle gain, or body improvement treatment(s) have you tried or are trying? Please provide details about what and when.*

Have you ever had or do you currently use any of the following: physical therapy, chiropractic massage, acupuncture, Feldenkrais, rolfing, Alexander technique, other? Please provide specifics.*

Have you ever worked with a personal trainer? If so, provide details.*

How many days per week do you have to commit to exercise? Approximately how many minutes per day?*

What does a typical week of workouts/daily movement look like for you? Be as specific as possible, including time spent training, nature of training (e.g. Crossfit, swimming, cycling, running, weight training, etc.)*

Are there any areas of your body that you consider “problem areas”? If so, which?*

The following section is designed to give us an idea of your current and potential training frequency and volume. If your schedule changes from week to week, that's OK. The main focus of this part of the questionnaire is to let us know what your current training schedule looks like, and how much potential flexibility you have in your training days/hours. If you feel that you can articulate this information better in an e-mail or phone conversation, let us know and then feel free to leave these spaces blank. There will be an opportunity later in the questionnaire to describe your actual workouts.

Provide information for only the training components below that are relevant to your training goals.

Swim Skill

Describe your swimming history:

Current swim schedule:

Potential Days/Hours Available for Swimming:

Cycling Skill

Describe your cycling history:

Current cycling schedule:

Potential Days/Hours Available for Cycling:

Run Skill

Describe your running history:

Current Run Schedule:

Potential Days/Hours Available for Running:

Weights/Core/Flexibility Skill

Describe your weights/core/flexibility history:

Current Weights/Core/Flexibility Schedule:

Potential Days/Hours Available for Weightlifting/Core/Flexibility Training:

The following questions are designed to give us a better idea of how you train and what type of workouts you perform. Be as specific as possible. If you utilize a power meter, heart rate monitor or heart rate training zones, describe your intensities. You can also describe your intensities using a rating of perceived exertion (1=easy, 10=hard) or an adjective (easy, long, hard, fast, short, etc.). Remember to indicate if you currently utilize bricks or combined workouts.

Current swim protocol, if any.

Current bike protocol, if any.

Current run protocol, if any.

Current weights/core/flexibility protocol, if any.

Describe any other sports in which you currently participate:

The following questions will help us determine the equipment and gear you currently use or have access to.

Please describe your home gym or health club training area including the equipment that you have available for weight training, cross training, mobility, etc.*

Please describe your swimming training and racing gear, including wetsuit, goggle/mask, skinsuit, fins, pull buoy, cap, gloves, socks, elastic swimming bands, aqua belt, etc.

Please describe your cycling training and racing gear, including bike, components, wheels, tires, aerobars, shoes, orthotics, helmet, trainer/roller, etc.

Have you had a professional bike fit?

Yes
No

If so, where?

Please describe your running training and racing gear, including shoe type.

Do you use orthotics?

Yes
No

Please describe.

Please describe any special electronic training or recovery equipment to which you currently have access (i.e. Garmin Forerunner, Polar HR Monitor, Computrainer, Powermeter, Oura ring, Whoop etc):

Please describe your weightlifting/core/flexibility gear, including free weights, bands, medicine balls, stability balls, and cross training equipment*

The following questions are designed to give us a clear idea of your training environment and access to areas for swimming, cycling, running, and other activities.

Please describe your access to pools and open water swim areas. Please include pool size, open water description (lake, river, ocean) and access limitations (year-round, weekdays only, etc.)

Please describe your biking environment, including information on your “favorite” courses near to your home or work, hill access description, areas to perform time trial tests, wind conditions, etc.

Please describe your running environment, including information on your “favorite” courses near to your home or work, hill access description, areas to perform time trial tests, track access, etc.

The following sections are designed to give us an idea of your skill limitations. Please choose the best possible answer. We realize that you may have multiple priorities or limitations, but choose an answer that is most relevant to you. If you would rather describe your limitations in your own words, please write in the space provided.

Swim:

I find it difficult to finish the swim portion of a race.
In choppy open water swims I lose more time than others in my race category.
My swim technique is poor.
My swimming gets slower as the race progresses.
If I start the swim fast I start gasping for air and must slow down more than others in my race category.
At the end of the swim portion I'm unable to speed up to catch those slightly ahead of me.
Other:

Run:

I usually find it difficult to finish long runs.
I run up hills slower than most in my race category.
I bounce up and down more than others when I run.
My running gets slower as the race progresses.
In shorter races, if I go anaerobic I'm forced to slow down.
I almost never win a sprint to the finish line.
Other:

Have you had a VO2 or blood lactate test? Please provide the results if available:

Do you currently complete field testing for lactate threshold, VO2 max, maximum heart rate, etc? If so please describe your field testing procedures and results:

Have you completed any additional tests, such as anaerobic power, resting metabolic rate, etc.? Is so please describe the procedure and results, if available:

Describe any sport-specific injuries or illnesses you currently have (i.e., knee or shoulder pains, exercise induced asthma, tendinitis, bursitis, diabetes, etc). Be as specific as possible. Include any medications, supplements, or treatments you are currently utilizing to address the problem.*

The following questions are designed to help us design your racing schedule, familiarize us with your desired races, and clearly outline your goals for this racing season. If you have already a race resume or potential race schedule, you may skip all of this section UNLESS you still need to prioritize your races.

How many years have you competed in races?

Describe your history with sprint distance racing, including approximate number of races completed, race year, race name, any significant race results, etc.

Olympic:

Half-Iron:

Iron:

Other (Ultra, Adventure Racing, Marathon, etc.):

Please list every race that you plan to compete in this year. Prioritize your races as high priority (attempting to win, podium, set a PR, complete as a racing milestone, or crucial to your season’s goals), medium priority (important race that requires a taper, but not crucial to your season’s goals), or low priority (for fun only). Please include any notes (annual “tradition” race, had a DNF last year, must travel significantly to attend, etc.). Copy and include extra sheets if necessary.

Race:

Date:

Priority:

Notes:

Race:

Date:

Priority:

Notes:

Race:

Date:

Priority:

Notes:

Race:

Date:

Priority:

Notes:

FINAL SECTION! Describe what you truly desire from working with Ben's Coaching Program. What do you want out of this season? Out of your sport? Out of life? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your goals? Be as honest and specific as possible, describing actual races, rankings, or outcomes you want to pursue. You may also use the following section to include any additional general notes for your coach. Include anything that you feel would be helpful that you haven’t yet had a chance to express.

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 exercise recommendations from Ben Greenfield and his affiliated coaches are merely a suggestion and not a prescription.

Please type full name here:*

Acknowledgment*

Acknowledgement

I understand I will receive a complete plan of exercise programming and access to a workout tracking platform. If I desire additional accountability and extended follow-up from my coach, I will opt for the Voxer plan 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.

Date

Fitness Plan Design Questionnaire

Contact Details

Lifestyle

Health History

Exercise Status

Provide information for only the training components below that are relevant to your training goals.

The following questions will help us determine the equipment and gear you currently use or have access to.

The following questions are designed to give us a clear idea of your training environment and access to areas for swimming, cycling, running, and other activities.

Activity Waiver