Returning-patient check-in — a shorter questionnaire that compares your progress against your first visit.
Confidential & HIPAA protected · Richard G. Spurlock, MD
Welcome — let's get started
Choose the option that fits your visit today.
Step 1 of 5Patient Information
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.
Used only to match this assessment to your chart.
—
Female
Male
Guides hormone screening.
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Medical History
Past medical and family history, diet.
Yes
No
Unknown
Female-specific history
Guides perimenopause / menopause status.
Yes
No
Unknown
HRT contraindication screen.
Current Medications
GLP-1 / HRT status and supplements.
No
Yes
No
Yes
No
Yes
Hormone replacement
No
Yes
Other medications
No
Yes
Long-term acid suppression triggers B12 / MMA screening and is relevant to gut health.
Goals
Your priorities help us tailor the plan.
Symptoms
Rate each item over the past 30 days. 0 = none, 1 = mild, 2 = moderate, 3 = severe.
Weight & Metabolic
Energy & Cognition
Hormone — Female
Sleep quality
STOP-BANG sleep apnea screen
No
Yes
Stress & HPA
1 (none)10 (extreme)
5
Gut Health
No
Yes
No
Yes
Safety screen
No
Yes
If yes, this is flagged urgent for Dr. Spurlock's review.
Step 1 of 4Identity
Welcome back
We'll match this check-in to your first visit, then compare your progress.
Please enter your last name and date of birth exactly as you did on your first visit so we can find your baseline. If they don't match, we won't be able to show your progress.
Female
Male
Symptom check-in
Rate each item over the past 30 days. 0 = none, 1 = mild, 2 = moderate, 3 = severe. We'll compare these to your first visit.
Weight & Metabolic
Energy & Cognition
Hormone
Sleep quality
Stress & HPA
1 (none)10 (extreme)
5
Gut Health
Your progress so far
All optional — fill in what applies to you.
Enter a negative number for weight lost (e.g., −12), positive for gained.
0 (not at all)10 (every day)
5
0 (not at all)10 (every day)
5
How are you feeling overall?
Rate each from 0 (worst) to 10 (best), compared to before you started.
In your own words
✓
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Your answers have been received and encrypted. Your scores will be reviewed
by a provider, and your personalized recommendations will be discussed with
you in person at your visit. There's nothing more you need to do right now.
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Assembled Plan — NBA Scoring Output
Generated from the patient's submission. Triggered sections carry labs, supplement stack, and pricing; the Care Coordinator handles next steps.