Physician-guided weight loss & wellness. Your answers build a plan tailored to you — please complete every section.
Confidential & HIPAA protected · Richard G. Spurlock, MD
v26 build — for clinical review. Contact info, allergies & medications are collected in Charm; this assessment powers the tailored plan.
Step 1 of 5Patient Information
Patient Information
Demographics and body metrics.
This form is the clinical assessment that powers your tailored plan. Your allergies, medications, and basic history are collected on your Charm patient intake — no need to repeat them. We ask for your name and date of birth to match this assessment to your chart, and optionally a phone or email so we can send you reminders.
—
Used only to match this assessment to your chart.
Optional — used for appointment and plan reminders.
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.
Your assessment is in.
Thank you — a provider will review your responses and follow up about next steps and your tailored plan. You don’t need to do anything else right now.