Intake Questionnaire/Records Review Summary (Functional Medicine)

Date of Review: [Date of review]

Reviewer: [Reviewer name, credentials, role]

Materials Reviewed:

• Patient questionnaires: [Questionnaire title(s) with completion date(s)] (Indicate incomplete sections if any; explicitly note if questionnaires were not received.)
• Outside records: [Source institution(s), clinician specialty if known, and date range] (Indicate whether records were patient-provided vs obtained directly; explicitly state if some or all requested records were not received.)

Note Purpose

[Brief statement clarifying this is a pre-visit synthesis of submitted materials to support the upcoming consultation; note intent to organize and triage information, not to establish new diagnoses or treatment decisions.] "No face-to-face or telehealth encounter occurred for this note."

Clinical Snapshot

(High-signal summary readable in under 30 seconds. Limit to 4–8 bullets. End each bullet with source tag: e.g., (patient questionnaire, [date]) or (outside record: [institution/clinician], [date]).)

• [Age, sex, relevant context such as pregnancy status] (source tag)
• [Top 1–3 reasons for visit in patient's words when available] (source tag)
• [Key established diagnoses and/or major symptom patterns] (source tag)
• [Salient risk factors: immunosuppression, anticoagulation, eating disorder history, severe psychiatric history, substance use, prior anaphylaxis] (source tag)
• [Most significant abnormal findings with dates] (source tag)

Patient Goals and Preferences

(Include only if questionnaires solicited goals or patient provided narrative. Include 1–2 brief direct quotes when they add clarity.)

• Priorities and desired outcomes: [Patient-stated goals and what success looks like; e.g., reduce specific symptoms, identify triggers, fertility goals] (source tag)
• Preferences and constraints: [Dietary preferences/restrictions, budget, time availability, cultural considerations, attitudes toward medications vs supplements vs elimination diets vs testing] (source tag)
• Functional impact: [Effects on work, sleep, exercise, daily activities, cognition] (source tag)

Key Problems (Prioritized)

(List problems in order: safety/acuity first, then degree of impairment, then patient priority. Attach source tags to key facts. Use non-judgmental language throughout.)

[Problem 1 label: neutral clinical term ± established diagnosis]

• Onset/timeline/pattern: [Onset, course, temporal pattern] (source tag)
• Triggers and modifiers: [Known triggers, relieving factors] (source tag)
• Associated symptoms: [High-yield positives and negatives; avoid exhaustive ROS] (source tag)
• Severity and functional impact: [Severity scale if given; impact on function] (source tag)
• Prior evaluation: [Pertinent tests/imaging/consults with dates and key values] (source tag)
• Prior treatments and response: [Medications, supplements, diets, lifestyle approaches; response/tolerance/adherence if known] (source tag)
• Current status: [Current frequency/severity/trend] (source tag)
• Open questions/hypotheses to explore at visit: [Items not yet assessed with the patient; avoid asserting diagnoses]

[Problem 2 label]

(Repeat structure for each additional problem as needed, maintaining prioritization.)

• Onset/timeline/pattern: [Onset, course, temporal pattern] (source tag)
• Triggers and modifiers: [Known triggers, relieving factors] (source tag)
• Associated symptoms: [High-yield positives and negatives] (source tag)
• Severity and functional impact: [Severity scale if given; impact on function] (source tag)
• Prior evaluation: [Pertinent tests/imaging/consults with dates and key values] (source tag)
• Prior treatments and response: [Medications, supplements, diets, lifestyle approaches; response/tolerance/adherence if known] (source tag)
• Current status: [Current frequency/severity/trend] (source tag)
• Open questions/hypotheses: [Items not yet assessed with the patient]

Records Timeline

(Include only when outside records are substantial—generally >10 pages or multiple institutions/specialists. Present 6–12 dated entries chronologically. Flag discordant information without speculating which source is correct. If records are minimal, omit this section and integrate into Key Problems.)

• [YYYY-MM-DD]: [Event type: hospitalization/ED visit/consult/new diagnosis/medication change/key lab or imaging/procedure] — [Key findings] (source tag)
• [YYYY-MM-DD]: [Event and findings] (source tag)
• [YYYY-MM-DD]: [Event and findings] (source tag)

Medications, Supplements, and Allergies

(Core safety section. Distinguish patient-reported lists from outside record medication lists and note discrepancies. If information is incomplete, explicitly state reconciliation is required.)

• Prescription medications:
  • [Name | dose | route | frequency | indication | start date if known] (source: [patient-reported / per outside record]; note discrepancies)
• OTC agents:
  • [Name | dose | frequency | reason for use] (source tag)
• Supplements, herbals, nutraceuticals:
  • [Product name (ingredient if known) | dose | frequency | brand if relevant | reason for use] (source tag)
• Allergies and intolerances:
  • [Allergen | reaction type | severity | true allergy vs intolerance if known] (source tag)
• Safety notes: [Duplicate agents, bleeding risk combinations, sedating combinations, pregnancy concerns, or other clear issues] (Mark uncertain items as "needs review at visit.")
• Reconciliation status: [Complete / Incomplete — reconciliation required at visit]

Lifestyle and Functional Context

(Include only domains with available data; omit domains without data. Use neutral, non-stigmatizing phrasing. List missing critical domains under Data Gaps.)

• Nutrition pattern and restrictions: [Typical intake patterns; dietary restrictions/preferences; notable eliminations] (source tag)
• Alcohol and caffeine: [Type, quantity, frequency] (source tag)
• Physical activity: [Type, frequency, duration, intensity; limitations] (source tag)
• Sleep: [Duration, quality, timing, disruptions] (source tag)
• Stress and mental health context: [Stressors, coping] (source tag) (Use trauma-informed sensitivity.)
• GI function patterns: [Bowel habits, bloating, reflux, other patterns] (source tag)
• Menstrual/reproductive history: [Cycle patterns, fertility context, pregnancy/postpartum status] (source tag) (Include when relevant.)
• Occupational/environmental exposures: [Shift work, chemical exposures, mold concerns, tick exposure, travel, pets] (source tag)
• Social support context: [Living situation, caregiving roles, support systems] (source tag)

Prior Workup (Key Results)

(Include if testing exists that will influence the plan or prevent duplicate testing. Summarize by body system or problem. Include units and reference ranges when available; state if unavailable. For nonstandard tests, note when methodology/clinical relevance should be reviewed. Omit section if no testing data provided.)

• [System/Problem]: [Test name] — [Date] — [Result with units and reference range if available] (source tag)
• [System/Problem]: [Imaging/procedure] — [Date] — [Salient findings] (source tag)
• [Nonstandard test]: [Vendor/lab] — [Specimen] — [Date] — [Reported findings] (source tag) (Note: methodology/clinical relevance to review.)

Red Flags and Safety Triage

(Always include this section. Document symptoms or results requiring action before the scheduled visit with recommended disposition per clinic policy.)

• [Red flag symptom or finding] — [Recommended disposition] (source tag)
• [Medication/supplement safety concern needing prompt clarification] (source tag)
• [Record integrity risk: e.g., missing pathology for abnormal biopsy, missing imaging for noted mass] (source tag)

(If no red flags identified, state:) No urgent red flags identified from submitted materials (limitations: incomplete data).

Data Gaps and Clarifications Needed

(Always include this section. Prioritize by safety, then visit efficiency, then secondary importance.)

• Records to request: [Institution/clinic, clinician, date range, specific documents needed]
• History elements to clarify at visit: [Targeted questions or missing details]
• Conflicting information across sources: [Describe discrepancy neutrally; list both sources and dates]
• Objective data to obtain at visit: [Vitals, anthropometrics, targeted labs/testing] (If supported by workflow.)

Proposed Visit Focus

(Include when complexity is high or questionnaires are extensive. Omit for straightforward intakes.)

• [Agenda item 1] — [achievable today / needs follow-up]
• [Agenda item 2] — [achievable today / needs follow-up]
• [Candidate referrals or coordination needs to consider]

Reviewer Signature: [Name, credentials] — [Date/time]

(Global guidance: Use patient-accessible, non-stigmatizing language throughout. Source attribution is mandatory for high-stakes facts. Acceptable inferences include simple calculations, timeline organization, and summarizing explicit report statements. Do not assert unconfirmed diagnoses, attribute causality, or over-interpret nonstandard tests. When safety-relevant information is missing, note as unknown and list under Data Gaps. Summarize source materials rather than reproducing lengthy text.)