New Client Questionnaire - Ben Greenfield Life - Health, Diet, Fitness, Family & Faith

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
Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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.*
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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
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- 4
- 5
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- 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.*
This field is hidden when viewing the form
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
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- 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?
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.
Do you suffer from back pain?
- Yes
- No
If you answered yes, please give details.
Are you sensitive to touch/pressure in any area?
- Yes
- No
If you answered yes, please give details.
Do you have tension, numbness or pain in a specific area?
- Yes
- No
If you answered yes, please give details.
Do you experience frequent headaches?
- Yes
- No
If you answered yes, please give details.
Are you pregnant?
- Yes
- No
If you answered yes, please give details.
Have you ever given birth?
- Yes
- No
If you answered yes, please give details
Do you have high blood pressure?
- Yes
- No
If you answered yes, please give details.
Do you have high cholesterol?
- Yes
- No
If you answered yes, please give details.
Have you ever had surgery?
- Yes
- No
If you answered yes, please give details.
Have you ever broken any bones?
- Yes
- No
If you answered yes, please give details.
Do you experience stiff, swollen or painful joints?
- Yes
- No
If you answered yes, please give details.
Do you have difficulty sleeping?
- Yes
- No
If you answered yes, please give details.
Do you experience fatigue or lack of energy?
- Yes
- No
If you answered yes, please give details.
Do you experience cold hands or feet?
- Yes
- No
If you answered yes, please give details.
Have you ever been advised by a physician to avoid any type of exercise?
- Yes
- No
If you answered yes, please give details.
Have you ever been knocked unconscious or suffered a concussion?
- Yes
- No
If you answered yes, please give details.
Do you (or does someone in your family) have a cardiac condition?
- Yes
- No
If you answered yes, please give details.
Do you have any known allergies?
- Yes
- No
If you answered yes, please give details.
Are you currently taking any medications (not nutrition supplements)?
- Yes
- No
If you answered yes, please give details.
Do you smoke or have you smoked in the past?
- Yes
- No
If you answered yes, please give details.
Are there any medical issues which have not been discussed on previous questions?
- Yes
- No
If you answered yes, please give details.
Your Exercise Status
Describe your current exercise routine, if any.
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
If you answered yes, please give details.
Do you count or track calories?
- Yes
- No
If you answered yes, 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
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- 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
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- 10 - lose weight
Do you constantly look forward to the next meal, frequently thinking about foods and what you want to eat?
- 1 - yes
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- 10 - no
What is your appetite like at breakfast?
- 1 - weaker
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- 10 - stronger
What is your appetite like at lunch?
- 1 - weaker
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- 10 - stronger
What is your appetite like at dinner?
- 1 - weaker
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- 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
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- 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
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- 10 - tired and hungry
What about if you ate a steak?
- 1 - energetic and satisfied
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- 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
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- 10 - 6-7x including snacks
How much do you enjoy sour foods like pickles, sauerkraut, or vinegar?
- 1 - love them
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- 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
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- 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 (include information about any current nutritional sponsors):
Use the following section to include any additional nutritional notes:
Your Final Thoughts
Your Goals
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

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Your Contact Details

Your Lifestyle

21 Important Questions About Your Health History

Your Exercise Status

Your Nutrition & Metabolism

Your Final Thoughts