Environmental Exposure Assessment Note (Functional Medicine)

Date of Service: [YYYY-MM-DD]

Clinician: [Clinician name, credentials]

Visit Type: [in-person / telehealth]

Participants: [Patient alone / Family present / Caregiver / Interpreter: language / Other]

(Global documentation guidance: Use absolute dates when available. Distinguish sources as "Patient-reported," "Observed," "Reviewed records," or "Working hypothesis." For missing clinically critical information, document "Not assessed (reason)," "Unknown," or "Negative" as appropriate. Frame exposure hypotheses with certainty qualifiers rather than stating causation without supporting data.)

Chief Concern

[Patient-stated reason for visit including suspected exposure context; use direct quote if available]

Clinical Snapshot

[Clinician-authored 1–2 sentence summary of key symptom(s), duration, most likely exposure context, and key modifier]

Safety Screen

(Include this section only when acute or serious exposures are plausible; omit entirely if not clinically relevant.)

• [Acute neurologic or respiratory symptoms in multiple co-exposed individuals: Yes / No / Unknown]
• [Recent combustion source exposure in enclosed/poorly ventilated space: Yes / No / Unknown]
• [Severe or rapidly progressive symptoms requiring emergency evaluation: Yes / No / Unknown]
• [Pregnancy with reproductive toxicant concern: Yes / No / Unknown / Not applicable]
• [High-hazard exposure scenario (CO, cyanide, hydrogen sulfide, organophosphate): Yes / No / Unknown]
• [Immediate disposition if any red flag positive: ED referral / Removal from exposure / Poison control contacted / Other]
• (If a relevant safety element was not assessed, document "Not assessed" with brief rationale.)

History of Present Illness

[Timing anchor and core concern or attribution] (Use absolute dates when possible.)

[Symptom course: onset, progression, episodic vs. constant, severity, frequency, functional impact] [Temporal relationships to specific locations/activities; time-to-onset after entering space; improvement when away] [Provoking/palliating factors: work schedule, ventilation changes, PPE/masks, weekends, vacations] [Associated symptoms across systems as relevant]

[Prior evaluations and results] [Treatments tried and response] [Direct quotes for hallmark concerns, unusual odors/irritants, or relevant third-party statements]

Exposure History

(Use brief bullets for straightforward cases. For complex multi-setting or fluctuating patterns, include the timeline table below.)

Exposure Timeline (Include only when complexity warrants; delete if not needed.)

Date range	Setting	Suspected agent(s)	Route	Symptom response	Others affected	Controls/PPE
[YYYY-MM to YYYY-MM]	[Home / Work / School / Other]	[Agent/product or unknown]	[Inhalation / Dermal / Ingestion]	[Temporal relation, onset, offset]	[Yes / No / Unknown]	[Ventilation, filtration, PPE type]

Occupational History

• [Current employer/industry (if patient consents)]
• [Job title and tenure]
• [Primary job tasks and work environment]
• [Materials/agents used; product names if known]
• [Ventilation/engineering controls]
• [PPE type, fit, frequency of use]
• [Hygiene practices: handwashing, eating in work area, laundering work clothes separately]
• [Symptom pattern relative to work schedule]
• [Coworker symptoms: Yes / No / Unknown]
• [Recent workplace changes: new chemicals, remodeling, water damage]
• [Relevant past jobs with approximate dates] (Expand only those with plausible exposures.)

Home and Residential Environment

• [Dwelling type, age, and date of move-in]
• [Recent renovations or repairs]
• [Moisture/water intrusion history; visible mold or musty odors]
• [HVAC type, filtration, ventilation practices]
• [Combustion appliances and CO detector status]
• [Cleaning products, fragrances, air fresheners]
• [Pest control methods]
• [Drinking water source and filtration]
• [Household member occupations] (For take-home exposure risk.)
• [Smoking or vaping exposure in the home]

Other Exposures

• [Hobbies/activities with chemical, dust, or fume exposure]
• [School/daycare or other frequented buildings if relevant]
• [Commuting exposures]
• [Recent travel and lodging environment]
• [Outdoor air quality factors: wildfire smoke, proximity to industry]

Mitigation Already Attempted

• [Change implemented and date] — [Patient-reported effect on symptoms]

Risk Modifiers and Susceptibility

(Include only factors materially relevant to the current exposure concern.)

• [Pregnancy status or intent]
• [Age-related vulnerability]
• [Pre-existing respiratory, allergic, or other relevant disease]
• [Immunocompromised status or relevant medications]
• [Smoking/vaping history]
• [Prior significant exposure history]

Pertinent Medical History

• [Focused problem list: conditions affecting susceptibility, differential, testing, mitigation, or safety]
• [Relevant allergies]
• [EHR histories: Reviewed and verified; new or changed information noted]

Objective

Vitals and General

• [Vital signs: BP, HR, RR, Temp, SpO2]
• [General appearance and respiratory/mental status observations]

Physical Examination

• [HEENT: conjunctival/nasal irritation, oropharynx]
• [Lungs: wheeze, prolonged expiration, crackles, work of breathing]
• [Skin: rashes, irritant/contact findings, distribution]
• [Neuro/cognitive screen as indicated]
• [Other focused findings pertinent to suspected exposure]

Data Reviewed

• [Prior labs/imaging with dates and key results]
• [External documents: building reports, industrial hygiene reports, SDS, product labels, symptom diaries, photos]
• [New tests ordered: test name, clinical question addressed, timing]
• [Information requested but pending: source and expected content]

Assessment

(List problems in descending clinical severity. Use explicit uncertainty qualifiers.)

[Problem #]: [Symptom syndrome or established diagnosis]

• Exposure hypothesis: [Suspected setting, agent, route] — [possible / probable / unlikely / cannot rule out]
• Supporting evidence: [Temporal association; improvement away; re-exposure effects; others affected; known irritant potential; objective findings]
• Contrary/limiting evidence: [Negative or inconsistent findings; alternative explanations]
• Differential diagnosis: [Exposure-related causes] / [Non-exposure causes]
• Clinical severity and safety risk: [Acuity; who else may be at risk]

(When causation is uncertain, include: "Causation cannot be confirmed at this time; evaluation focuses on risk reduction and diagnostic clarification.")

(Repeat problem section as needed for additional problems.)

Plan

(Problem-oriented, addressing both clinical evaluation and exposure mitigation. Include only relevant subsections.)

[Problem #]

• Immediate Safety Actions: [Removal from exposure / Work restriction / Relocation / ED referral / Poison control] [Return precautions] (Include only when indicated.)
• Diagnostic Evaluation: [Test(s) ordered, clinical question, how result changes management, timing]
• Environmental Evaluation: [Information to obtain: SDS, building reports] [Consults: industrial hygiene, building science, occupational medicine] [Sampling rationale and interpretation plan if applicable]
• Mitigation Plan:
  • [Source removal/substitution]
  • [Engineering controls: ventilation, filtration, containment]
  • [Administrative controls: limit time, task rotation, scheduling]
  • [PPE: type, fit, limitations]
  • [Hygiene controls: handwashing, clothing change, separate laundering]
• Symptom Management: [Treatments and safety counseling; note if interim pending mitigation]
• Referrals: [Service and specific clinical question]
• Patient Education: [Uncertainties discussed; risks/benefits explained; patient understanding; resources provided]
• Third-Party Documentation: [Work note / Housing letter / School accommodations; patient authorization status] (Include only when needed.)
• Follow-up: [Interval and modality] [What to track: symptom diary, peak flow] [Data to review]

(Repeat plan section for additional problems, or consolidate if shared.)

Time and Medical Decision-Making

(Optional; include for billing support per organizational guidance.)

• [Total time on date of service: XX minutes] OR
• [MDM elements: problems addressed; data reviewed and ordered; risk level]