Initial Consultation Note (Herbal Medicine)

Date/Time: [Encounter date and time] (Enter actual date and time; do not leave blank)

Patient Name: [Patient full name]

DOB: [Date of birth]

Visit Type: [new patient initial consultation / follow-up consultation]

Location: [Clinic name and site]

Referral Source: [Self / PCP / Specialist / Other with name if available]

Practitioner: [Practitioner name and credentials] (Enter actual author; do not leave blank)

Data Sources: [Patient interview / intake forms / outside records / medication bottles reviewed / pharmacy list / caregiver report / other] (List all sources actually reviewed today)

Chief Concern

[Primary reason for consultation in patient's own words when available; consultation intent; red-flag symptoms if present] (1–2 lines; note any urgent concerns requiring immediate attention)

Patient Goals and Preferences

• Short-term goals: [Patient-stated goals with measurable endpoints]
• Long-term goals: [Patient-stated goals with measurable endpoints]
• Success looks like: [Patient's description of expected outcomes]
• Constraints/Preferences: [Preparation preferences; pill burden limits; cost considerations; alcohol-free preference; sedation concerns; interaction concerns; taste/format preferences]
• Baseline metrics for tracking: [Symptom severity rating; frequency/duration metrics; sleep latency; headache days per month; energy level; other relevant baseline values]

History of Present Illness

[Chronological narrative: onset, duration, course, severity pattern, triggers, relieving factors, associated symptoms, functional impact, relevant context including stressors, diet changes, new medications, or life events; prior evaluations and diagnoses; response to conventional and complementary treatments tried with benefit/no benefit/adverse effects noted; safety-relevant context when applicable including pregnancy possibility, anticoagulant use, upcoming surgery, hepatic or renal disease history]

Health History

• Past Medical History: [Problem list with approximate onset dates and current status across cardiometabolic, psychiatric, GI, endocrine, autoimmune, and other relevant systems]
• Surgical History: [Major surgeries with dates if known; complications; implanted devices]
• Allergies and Adverse Reactions: [Drug allergies; food allergies; botanical/supplement reactions with reaction type and severity] (Do not document "no known allergies" unless explicitly assessed with patient)
• Reproductive Health: [LMP; pregnancy status or intention; contraception; breastfeeding; menopause status] (Include when relevant to botanical safety considerations)

Current Medications and Supplements

(Reconcile using all available data sources. If details are unknown, document explicitly and add follow-up action to obtain bottles/photos before regimen changes.)

• Item 1:
  • Product name: [Name on label]
  • Category: [Rx / OTC / vitamin-mineral / botanical / other]
  • Dose and frequency: [Dose, route, schedule]
  • Indication: [Reason for use]
  • Start date: [Approximate start date]
  • Adherence: [consistent / intermittent / as needed]
  • Perceived benefit: [Yes / No / Unclear with brief note]
  • Adverse effects: [None / described effect]
  • For botanicals: [Common name (Latin binomial); plant part; preparation form; manufacturer/brand; strength/ratio if known] (Include when applicable)
• Item 2: [Repeat structure for each therapy]

Reconciliation summary: [2–4 line narrative highlighting high-risk medications such as anticoagulants, immunosuppressants, serotonergic agents, or narrow therapeutic index drugs; potential interactions; duplicate therapies; poly-supplement patterns; products with unclear ingredients]

Unknown details and follow-up: [Document unknown brand/dose information with assigned action such as patient to bring bottles or photos to next visit]

Prior Botanical and Complementary Therapy Experience

• By product or condition: [Products tried; duration; response including benefit, no benefit, or adverse effects; clinician-guided versus self-directed use]
• Beliefs and preferences: [Preferences for whole herb versus standardized extracts; safety concerns; prior education or training in herbal medicine]

Social History

• Diet pattern: [Typical intake; restrictions; notable changes]
• Caffeine: [Amount and timing]
• Alcohol: [Type, amount, frequency]
• Substance use: [Tobacco/nicotine; cannabis; other]
• Sleep: [Schedule, latency, awakenings, quality]
• Physical activity: [Type, frequency, duration]
• Stress and coping: [Stressors; coping strategies; supports]
• Occupation and exposures: [Role; shift work; relevant exposures]

Family History

[First-degree family history relevant to presenting concerns and risk stratification]

Review of Systems

(Focus on chief concern with pertinent positives and negatives. Explicitly screen for red flags and document action if present.)

• Pertinent systems: [Symptoms relevant to presenting concerns]
• Red-flag screening: [Chest pain; syncope; GI bleeding; jaundice; dark urine; severe rash; suicidal ideation; severe allergic symptoms] (If present, document immediate action or referral)

Objective Findings

(Only include values actually measured or reviewed today)

• Vitals: [BP; HR; weight; other as measured]
• Physical Exam: [Systems examined and findings] (Omit section if not performed)
• Data Reviewed: [Prior labs or imaging with dates and key results] (List new tests ordered under Plan)

Assessment

(Numbered problem list in order of clinical importance. Distinguish patient-reported diagnoses from clinician-assessed problems. Use qualifying language appropriately.)

1. [Problem 1]: [Clinical summary synthesizing subjective and objective findings; working diagnosis or differential; contributing factors labeled as suspected versus confirmed; red flags ruled in or out]
2. [Problem 2]: [As above]

Plan

Plan discussed with patient using shared decision-making.

(Organize by problem; repeat structure for each problem addressed)

[Problem]: Therapeutic Plan

• Therapeutic goals: [Link to patient-stated outcomes with measurable targets and timeframe]
• Lifestyle and non-herbal recommendations: [Sleep hygiene; diet modifications; physical activity; stress management; conventional options discussed; referrals]
• Herbal recommendations:
  • Product: [Common name (Latin binomial if known); plant part; preparation form]
  • Dose and schedule: [Exact dosing with titration plan if applicable]
  • Duration: [Trial length and reassessment timeframe]
  • Target symptoms: [Link to baseline and goal metrics]
  • Patient-specific precautions: [Pregnancy/lactation potential; anticoagulant use; hepatic/renal concerns; sedation risk; upcoming procedures]
  • Interaction screening: [High-risk medications reviewed; key interaction considerations for this patient]
  • Stop rules: [Symptoms requiring discontinuation and clinician contact]
  • Procurement: [Dispensed / patient to purchase; brand specified if applicable; note if proprietary blend with constituents availability]
• Monitoring: [Symptom tracking method; home vitals if relevant; lab timing if ordered; expected time to effect]
• Coordination: [PCP notification; specialist referrals; records requested]

Safety Counseling and Informed Consent

• Supplement regulation counseling: [Discussed that dietary supplements are not FDA-approved for efficacy; quality and potency may vary; natural does not mean without risk]
• Interaction and safety counseling: [Specific interaction risks reviewed for patient's current medications and conditions; avoidance around procedures if indicated; alcohol content and sedation considerations]
• Adverse event instructions: [Symptoms requiring product discontinuation and clinician contact; when to seek urgent or emergency care]
• Medication/supplement list management: [Patient instructed to maintain updated list for all clinicians; bring bottles to visits]
• Informed consent: [Options presented including no herbal therapy and conventional alternatives; risks, benefits, and uncertainties discussed; patient questions answered; patient agrees to proceed] (Document specific consent for higher-risk regimens)

Follow-up

• Next appointment: [Timeframe or date]
• Patient to bring: [Medication/supplement bottles or photos; symptom diary; BP log; lab work if ordered]
• Interim contact: [How to reach clinic for concerns before scheduled visit]

(Do not infer information not obtained. For authorship and encounter date/time, enter actual values. For medications/supplements with unknown details, document uncertainty with follow-up action. Only include objective data actually measured or reviewed.)