Allergy Evaluation and Treatment Plan Note (Naturopathic Medicine)

Date/Time: [date and time]

Patient: [patient name, DOB]

Visit Type: [new patient / follow-up] [in-person / telehealth]

Provider: [provider name and credentials]

Chief Concern and History

[Patient-stated reason for visit] (Include direct quote when it clarifies the concern.)

[Symptom pattern, severity, and timeline] (Describe relevant domains—nasal/ocular, respiratory, skin, GI, systemic—with onset, timing, seasonality, suspected triggers, and functional impact. Omit domains not relevant to the presenting concern.)

[Prior evaluation and treatments] (Summarize prior testing with type, date, and key results. Document prior conventional and naturopathic treatments with response. Include relevant atopic history, family history, and patient goals that inform today's plan. Use placeholders when information is expected but unavailable, e.g., "Outside records pending.")

Medications, Supplements, and Adverse Reactions

Current Medications and Supplements:

• [medication or supplement name, dose, frequency, indication] (Include all prescriptions, OTC medications, and supplements/botanicals. For supplements, include formulation and manufacturer if known. If incomplete: "List incomplete—patient to provide.")

Allergies and Adverse Reactions:

• [substance] — [reaction type, severity] — [confirmed / patient-reported] (Do not label vague side effects as allergies. If none: "No known allergies per patient.")

Objective

Exam: [pertinent targeted findings] (Include general appearance and focused allergy exam as relevant: nasal mucosa, oropharynx, eyes, skin, lungs. For telehealth, note observational and patient-assisted findings. Omit systems not assessed.)

Data Reviewed: [relevant labs, prior testing, outside records] (Include source and dates. If none: "None reviewed today.")

Assessment

1. [Problem: working diagnosis or differential, severity, key supporting features, and safety considerations] (Order by clinical risk, then patient priority. Include anaphylaxis risk, asthma control status, or pregnancy/lactation when relevant.)
2. [Additional problem if applicable]

Plan

1. [Problem 1]: [patient goals and shared decision-making; environmental controls if applicable; conventional therapeutics with dose and duration; naturopathic/botanical interventions with dose, evidence limitations if weak, interaction screening performed, and stop criteria; testing or referrals with indication; follow-up metric with baseline, target, timeframe, and escalation criteria] (For systemic reaction risk: include epinephrine prescription/education and anaphylaxis action plan.)
2. [Problem 2]: [plan elements as above] (Include only if applicable.)

Safety Net: [red flag symptoms and instructions for urgent/emergent care] (Include after-hours guidance. For systemic reaction risk: reiterate epinephrine thresholds and emergency follow-up criteria.)

(Omit sections not assessed. Do not infer findings not directly observed or reported.)