Functional Medicine Follow-Up Visit Note (In-Person or Telehealth)

Date/Time: [Encounter date and time]

Patient: [Patient name and identifier]

Clinician: [Clinician name and credentials]

Visit Type: [post-test review / care-plan revision / maintenance follow-up / other]

Modality: [In-person at (location) / Telehealth – see attestation below]

Chief Concern & Visit Goals

[Chief concern in patient language, 1–2 lines]

[Patient-stated goals for today's visit: symptom priorities, labs to review, adherence barriers, treatment decisions]

Interval History

[Narrative summary of interval course since last visit: time elapsed, overall trajectory, key improvements or setbacks, urgent developments] (4–6 sentences.)

Adherence & Response: [For each relevant domain—nutrition, supplements, medications, sleep, movement, stress regulation—document: recommendation → adherence → outcome → barriers. Include only domains addressed in the care plan.]

Intercurrent events: [Medical events, specialist visits, major life changes affecting symptoms or adherence] (Omit if none.)

Safety screening: [Red-flag symptoms, behavioral health concerns, substance use, pregnancy status if relevant] (If clinically indicated but not assessed, write "Not assessed today." Omit section if not applicable.)

Medications, Supplements & Allergies

Medications: [Current prescription and OTC medications with dose, frequency; note changes since last visit]

Supplements/Botanicals: [Current supplements with dose, frequency, indication, tolerability; note changes since last visit]

Allergies: [Drug/food/environmental allergies with reaction type; distinguish true allergy vs intolerance] (If unknown, write "Unknown.")

Objective

Vitals: [As obtained] (For telehealth, note patient-reported source. If not obtained, write "Not obtained.")

Exam: [Targeted findings relevant to active problems] (For telehealth, document limited exam with observed elements only.)

Data Reviewed: [Labs, imaging, questionnaires, patient-generated data with dates, key findings, and clinical interpretation; note how findings inform today's decisions]

Assessment & Plan

[Brief synthesis of overall clinical impression and progress toward goals]

Problem 1: [Problem name] – [improved / stable / worsened]; [supporting evidence from history and data]; [functional medicine hypothesis if applicable—label as hypothesis]; Plan: [diagnostics, therapeutic changes, de-prescribing, referrals, monitoring parameters, follow-up timing]; Safety-netting: [escalation criteria and contingency instructions]

(Repeat for additional problems, numbered and prioritized by acuity, functional impact, and patient priorities.)

Follow-up: [Next visit timing; what to track between visits; criteria for sooner contact]

Telehealth Attestation

(Include only if visit conducted via telehealth.)

Modality: [audio-video / audio-only] | Patient location: [city, state] | Clinician location: [if required] | Consent: Verbal consent obtained | Participants: [if others present] | Limitations: [exam/assessment limitations and impact on clinical decisions; contingency plan for in-person evaluation if needed]