PhySlim — Patient Health Questionnaire

Patient Information

Demographics and body metrics.

This form is the clinical assessment that powers your tailored plan. Your contact info, allergies, medications, and basic history are collected on your Charm patient intake — no need to repeat them. We ask only for your name and date of birth so we can match this assessment to your chart.

Full name *

Date of birth *

Used only to match this assessment to your chart.

Age

—

Today's date

Sex assigned at birth *

Female

Male

Guides hormone screening.

Height *

Current weight (lbs) *

BMI

—

Goal weight (lbs)

Medical History

Past medical and family history, diet.

Past medical history — check all that apply

Other conditions not listed When was your last comprehensive lab work? Family history of premature heart disease (CAD before 55 in men, 65 in women)?

Yes

No

Unknown

Diet pattern

Current Medications

GLP-1 / HRT status and supplements.

Are you currently on a GLP-1 or GIP/GLP medication? (semaglutide, tirzepatide, etc.)

No

Yes

Hormone replacement

Currently on hormone replacement therapy?

No

Yes

Other medications

Currently taking a PPI or H2 blocker? (omeprazole, esomeprazole, famotidine, etc.)

No

Yes

Long-term acid suppression triggers B12 / MMA screening and is relevant to gut health.

Current supplements — check all that apply

Other supplements not listed

Goals

Your priorities help us tailor the plan.

In your own words, what brings you here and what do you hope to achieve? * Primary goal — choose one

Secondary goals — select any that apply

When in your life were you most metabolically healthy? What was different then?

Symptoms

Rate each item over the past 30 days. 0 = none, 1 = mild, 2 = moderate, 3 = severe.

Weight & Metabolic

Pre-existing metabolic diagnoses — check all that apply

Morning fasting state — which fits best?

Energy & Cognition

Hormone — Female

Sleep quality

Average hours of sleep per night

STOP-BANG sleep apnea screen

Do you wake regularly between 2–4 AM (then struggle to fall back asleep)?

No

Yes

Stress & HPA

Self-rated stress level over the past month

1 (none)10 (extreme)

5

Gut Health

Diagnosed with an autoimmune condition?

No

Yes

Have you taken 3 or more courses of antibiotics in the past 5 years?

No

Yes

Safety screen

Do you experience chest pain or pressure with exertion?

No

Yes

If yes, this is flagged urgent for Dr. Spurlock's review.