Follow-Up Visit Note (Herbal Medicine)

Date: [Date]

Patient: [Patient name and identifiers]

Provider: [Provider name and credentials]

Visit Type: Follow-Up Visit (Herbal Medicine)

Visit Modality: [in-person / telehealth]

Reason for Visit & Interval History

[Visit agenda] (Briefly state the patient's primary concerns and the clinician's objectives for this follow-up.)

[Interval history since last visit] (Anchor to the prior plan by referencing what was started, continued, or stopped. Summarize symptom trajectory [improved / worsened / stable], functional impact on daily activities, intercurrent events, and any independent changes made by the patient such as self-titration or new supplements.)

Adherence: [Adherence verification] (Explicitly state whether the regimen was taken as prescribed. Document missed doses, timing deviations, and barriers. Do not infer adherence from symptom response.)

Tolerability & Safety: [Adverse effects review] (List suspected side effects with onset, severity, and actions taken. If no adverse effects occurred, state: "No adverse effects reported since last visit.")

Objective

(Include only when clinically relevant data were obtained or reviewed. If none, state explicitly that no objective data were collected this visit.)

Vitals: [Relevant vitals if obtained]

Exam: [Focused examination findings by system if performed]

Data Reviewed: [Pertinent labs, imaging, patient-generated data such as symptom diaries or home monitoring logs]

Assessment

[Summary statement] (1–2 sentences identifying the patient, key problem(s), and overall interval trajectory.)

[Problem 1]: [Working diagnosis] — [improving / stable / worsening]; [controlled / uncontrolled]. [Key supporting evidence from interval history and objective data. Note contributing factors and safety considerations such as interaction risk, organ function, or pregnancy/lactation as applicable.]

[Problem 2]: [Working diagnosis] — [improving / stable / worsening]; [controlled / uncontrolled]. [Supporting evidence and safety considerations.] (Include additional problems only as needed.)

Medication Reconciliation: [Attestation that medication and supplement list was reviewed and updated, interaction risks assessed, and gaps in product identification noted with plan to obtain missing information.]

Plan

(Organize by problem. Ensure the Current Herbal Regimen section reflects final, up-to-date product details.)

[Problem 1]: [Herbal regimen changes: continue/stop/taper/start/substitute with dose, frequency, timing, duration, and contingency rules as applicable. Lifestyle adjustments with at least one measurable element. Monitoring plan with symptoms to track, labs if indicated, and timeframe. Coordination needs including communication with other providers.]

[Problem 2]: [Regimen changes, lifestyle adjustments, monitoring, and coordination as applicable.] (Include only if applicable.)

Patient Education: [Risks/benefits discussed, interaction precautions, peri-procedural hold instructions if relevant, return precautions including symptoms that should prompt stopping products or seeking urgent care.]

Follow-Up: [Planned timeframe and modality, data to bring next visit, criteria for earlier follow-up.]

Current Herbal Regimen

(Single source of truth for active herbal products. Update whenever the plan changes the regimen. When proprietary blends limit detail, document what is known and note limitations.)

• [Product/formula name] ([botanical name and plant part if available]): [Preparation form] — [dose per unit], [total daily dose], [route and frequency], [timing instructions]. Indication: [linked problem]. Started: [date]. Brand: [brand or "unknown"]. Source: [label photo / patient recall / unknown]. (If source unknown, note plan to obtain.)
• [Product/formula name] ([botanical name and plant part if available]): [Preparation form] — [dose per unit], [total daily dose], [route and frequency], [timing instructions]. Indication: [linked problem]. Started: [date]. Brand: [brand or "unknown"]. Source: [label photo / patient recall / unknown].

(Add or remove product entries as needed.)