Wellness Questionnaire

Full Name *

Email *

Phone *

Age *

Gender *

Male

Female

Others

What is Your Main Goal for This Program? *

Weight Loss

Gain Muscle

Improve General Health

Feel More Energy

What Do You Feel is the Biggest Barrier in Your Wellness Journey? *

Accountability to stay on track

Knowledge of what to do

Curbing cravings

Busy lifestyle making it hard to stick to a plan

Are you a member of MAX Fitness & Wellness or Farrell's eXtreme Bodyshaping? If you are currently not a member at one of our locations, please select 'Not a Member' from the dropdown menu. *

Which MAX location are you a member at? *

Which Farrell's location are you a member at? *

Please enter your zip code so we can locate your nearest center. *

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Welcome to My Wellness Coach!

Take this quick quiz to find out how we can help you achieve your wellness goals.