Congratulations on choosing to optimize your body and health through a Ben Greenfield coaching plan. Ben will customize your entire program, but first Ben must assess your goals, and current level of health and fitness through the questionnaire below.

Ben’s Executive Assistant team will contact you for scheduling with 48 hours after completion of this form. Please remember to push the “submit” button at the bottom of this page.

  • Your Contact Details

  • Your Lifestyle

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  • 21 Important Questions About Your Health History

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

  • Your Nutrition & Metabolism

  • Your Final Thoughts

  • Describe what you truly desire from completing this program. What do you truly desire? 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.

    Yours in health,

    Ben Greenfield