TME FITNESS SOLUTIONS LLC
Michel Theodore, CPT, CHNC
Contact information:
Theodoremij@gmail.com
(860) 797 - 5061
Health Questionnaire
Personal Information
Date
Full Name
First Name
Last Name
Height
Weight
Age
Female-Male
Female
Male
Transgender
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
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9
10
11
12
13
14
15
16
17
18
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20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
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1990
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1988
1987
1986
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1984
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1982
1981
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1948
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1945
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
E-mail
Phone Number
-
Area Code
Phone Number
How can I I help?
Is it easy to put on weight and hard to lose it?
Yes
No
Maybe
Any health concerns? If so explain
No
Other
Do you get irritable easily?
Yes
No
Do you have low energy levels?
Yes
No
Do you suffer from symptoms of depression?
Yes
No
Do you have spine deterioration, herniated discs, or bone spurs?
Yes
No
Have you been diagnosed with Hashimoto or Reidel disease? Has a family member?
Yes
No
Family member
How much do you sweat?
Low
Medium
A lot
Do you have anxiety attacks, or feel overly anxious?
Yes
No
Do you feel excessive shyness or inferior to others?
Yes
No
Do you have High or Low Blood Pressure?
High
Low
Average
Do you have hypoglycemia (low blood sugar)?
Yes
No
Do you have Diabetes (high blood sugar)?
Yes
Type I
Type II
No
Do you have shortness of breath or is it hard to take a deep breath?
Yes
No
Do you have heart arrhythmias?
Yes
No
Do you have a hard time sleeping or insomnia? (pineal)
Yes
No
Females Only
Are your menstruation's irregular? (pituitary)
Yes
No
Do you get excessive bleeding during menstruation?
Yes
No
Are you currently pregnant?
Yes
No
Chemical Medications
List any medications you are currently taking
Approx Date of your last physical exam?
Medication Names and Reason for taking:
Natural Supplements you are on currently
Allergies
Past Surgeries - major and minor, and the year
What are your major health concerns (please list anything that was not addressed in this questionnaire):
Option to attach eye photo
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Option to upload any document you feel is relevant
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Thank you!!
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