Functional Medicine Initial Consultation Note (Comprehensive)

Date/Time: [Encounter date and time] | Location: [in-person / telehealth] | Visit type: New patient | Author: [Author name, credentials] | Scribe: [Name] (Include only if applicable) | Source of history: [patient / family / records / questionnaire] | Limitations: [language barrier / missing records / cognitive limitations] (Omit if none)

Chief Concern(s) and Visit Agenda

• [Chief concern 1 in patient's own words]
• [Chief concern 2]
• [Chief concern 3] (Include only if stated)

[Clinician-confirmed agenda for today; items deferred to follow-up with brief rationale]

Patient Narrative / History of Present Illness

[Narrative of symptom onset, time course, context, exacerbating/relieving factors, severity, and functional impact] (Use 2–6 concise paragraphs; integrate pertinent positives and negatives that narrow the differential; weave in relevant life events, stressors, sleep, diet, or exposures only as they relate to the clinical picture)

[Prior evaluations and treatments: what helped, what did not, adverse effects] (Summarize in narrative; avoid lists unless timeline is complex)

[Patient goals or beliefs in brief quotes if clinically useful]

Patient Goals, Values, and Readiness

• Goals: [Near-term goal(s)]; [Long-term goal(s)] (Convert to measurable targets when possible)
• Values/Preferences: [Dietary preferences / cultural considerations / cost constraints / supplement or pill-burden preferences]
• Readiness/Confidence: [Behavior change 1]: [0–10]; [Behavior change 2]: [0–10] (Include only if assessed)
• Barriers: [Time / finances / caregiving / food access / other]
• Supports: [Family/friends / community resources / health coach / other]

Functional Medicine Timeline

• [Approximate date or age]: [Key event] ([Antecedent / Trigger / Mediator-Perpetuator]) → [Brief clinical relevance]
• [Approximate date or age]: [Key event] ([Antecedent / Trigger / Mediator-Perpetuator]) → [Brief clinical relevance]
• [Additional entries as needed]

[1–2 sentence synthesis of key turning points and patterns]

Medical History

Past Medical History: [Chronic conditions, major diagnoses, hospitalizations, significant injuries with onset and current status]

Surgical History: [Procedures with approximate dates]

Medications:

• Prescription: [Name – dose – frequency – indication]; [Adherence issues or adverse effects if relevant]
• OTC: [Name – dose – frequency – indication]
• Supplements/Herbals/Nutraceuticals: [Name – dose – frequency – indication]

(If medication list not obtained: "Not obtained today—[reason]. Plan: obtain comprehensive list at [next visit / via records] and reconcile.")

Allergies: [Medication allergies with reaction type]; [Food allergies vs. intolerances, clearly distinguished] (If not obtained: "Not obtained today—[reason]. Plan: verify at next contact.")

Family History: [First-degree relatives with emphasis on early CVD, autoimmune, metabolic, psychiatric, or substance use patterns relevant to presentation]

Social and Lifestyle History

• Living situation: [Household composition, caregiving roles]
• Occupation/work schedule: [Role, hours, shift work, job strain]
• Substances: [Alcohol]; [Nicotine]; [Cannabis]; [Caffeine] (Quantify when provided)
• Physical activity: [Type, frequency, duration; sedentary time]
• Stress and coping: [Sources of stress, coping strategies]
• Environmental/exposure history: [Mold/water damage / occupational chemicals / air quality concerns] (Include only if relevant to presentation)
• Sexual and reproductive history: [Cycles, contraception, pregnancy history, menopause/andropause] (Include only if relevant)

Nutrition History

[Dietary pattern: overall style, typical meals, timing, protein and fiber adequacy, hydration; key restrictions with reasons; food access constraints] (Pattern-level summary)

Sleep History

[Sleep timing, latency, awakenings, snoring/apnea risk factors, restorative quality]

Prior Testing Summary

• [Test name and date]: [Salient result(s)] → [Brief interpretation] ([patient-reported / records reviewed])
• [Specialist evaluations and procedures with dates] → [Concise takeaways]

Review of Systems

• [System]: [Pertinent positives]
• [System]: [Salient negatives that narrow the differential]

(Include only if adding information beyond HPI; do not autopopulate negatives; omit systems not reviewed)

Physical Examination

• Vitals: BP [value]; HR [value]; RR [value]; Temp [value]; SpO2 [value]; Ht [value]; Wt [value]; BMI [value]; Waist circumference [value] (Include orthostatics if indicated)
• General: [Appearance]
• HEENT: [Pertinent findings]
• Neck: [Thyroid, lymph nodes]
• Cardiovascular: [Rate, rhythm, murmurs, perfusion]
• Respiratory: [Effort, auscultation]
• Abdomen: [Tenderness, organomegaly, bowel sounds]
• MSK: [Range of motion, tenderness]
• Neuro: [Orientation, focal deficits]
• Skin: [Rashes, lesions]
• Psych: [Mood, affect]

(Document pertinent positives and relevant normals targeted to chief concerns; omit systems not examined)

Data Reviewed

• Labs reviewed: [Test and date] → [Brief interpretation]
• Imaging reviewed: [Study and date] → [Brief interpretation]
• External records: [Source and date] → [Key takeaways]
• Patient-generated data: [Sleep logs / CGM / symptom trackers] → [Key patterns] (Label as patient-reported)

Functional Medicine Matrix

Matrix Summary: [1–3 sentence synthesis identifying most upstream drivers and most burdensome current issues; highest-leverage starting points]

(Include only nodes with meaningful clinical content; omit nodes without relevant findings)

Assimilation (digestion, absorption, microbiome)

• Evidence: [Key observations, labs, symptoms]
• Working hypothesis: [Pattern suggests…]

Defense and Repair (immune function, inflammation, infection)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Energy (mitochondrial function, oxidative stress)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Biotransformation and Elimination (detoxification, excretion)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Transport (cardiovascular, lymphatic)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Communication (hormones, neurotransmitters, immune messengers)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Structural Integrity (musculoskeletal, membranes)

• Evidence: [Findings]
• Working hypothesis: [Pattern suggests…]

Center (mind, emotion, spirit): [Brief note] (Include only if discussed and clinically relevant)

Foundational Lifestyle Factors: [Nutrition / sleep / movement / stress / relationships] → [How these relate to Matrix assessment and intervention priorities]

Assessment

1. [Problem 1]: [new / established]; [stable / uncontrolled] — [Brief evidence summary]. [Differential diagnosis if not established]. [Functional medicine framing: relevant ATMs and Matrix nodes]. [Red flags addressed if applicable].

2. [Problem 2]: [Status] — [Evidence]. [Differential if applicable]. [FM framing].

3. [Optimization/Prevention goal]: [Brief rationale].

(Prioritize: medical risk first, then symptom burden, then optimization goals)

Diagnostic Plan

• [Problem/Domain]: [Test name] — [Clinical question and how results will change management]; [Timing and preparation: fasting / cycle timing / supplement holds]
• [Additional Problem/Domain]: [Test(s) with rationale and logistics]
• Records/Referrals: [External records requested; referrals for diagnostic procedures]

(Note what is deferred and why if relevant to patient expectations)

Treatment Plan

Phase 1 Summary (first 2–6 weeks):

• [Do-first priority 1]
• [Do-first priority 2]
• [Do-first priority 3]
• [Additional high-impact action] (3–6 bullets total)

By Problem:

[Problem 1]

• Lifestyle: [Specific behavior, frequency, tracking method]
• Nutrition: [Start/stop/avoid/add; duration; rechallenge plan if elimination approach]
• Supplements: [Name – dose – schedule – duration – indication] (Include counseling on risks, interactions, contraindications)
• Medications: [New or changed medications with indication and monitoring plan]
• Referrals: [Dietitian / health coach / behavioral health / PT / specialty]

[Problem 2]

• [Interventions as above, organized by category]

Return Precautions: [Specific symptoms warranting urgent evaluation]

Shared Decision-Making

• Options discussed: [Including watchful waiting if applicable]
• Risks/benefits/uncertainties: [For supplements, elimination diets, off-label approaches]
• Patient questions and preferences: [Summary]
• Evidence of understanding: [Teach-back or verbal confirmation]

Follow-up and Coordination

• Follow-up: [Interval] via [in-person / telehealth / message]
• To review at next visit: [Labs / food logs / symptom trackers / device data]
• Coordination tasks: [Records to obtain / referrals placed / care team communication]
• Results communication: [How results will be delivered; plan for urgent abnormalities]

Billing Support

(Include only if needed for billing documentation)

• Time-based: Total time [minutes] on encounter date: [Pre-visit review] / [Face-to-face] / [Documentation] / [Care coordination]
• MDM-based: [Problems addressed with severity]; [Data reviewed and ordered]; [Risk of management options]
• Attestations: Medication list reviewed and reconciled. Allergies reviewed. [Scribe attestation if applicable]

Signature: [Author name, credentials] — [Date/Time signed]

(Global instructions: Use narrative paragraphs for patient story and summary impressions; use bullets for objective data, Matrix nodes, and plan items. Omit sections where information was not collected and is not safety-critical. For safety-critical missing data such as medications or allergies, state "Not obtained today—[reason]" with plan to obtain. Label functional medicine hypotheses explicitly; do not present as definitive diagnoses without conventional diagnostic support. Summarize prior results rather than copying full reports.)