Integrative/Functional Medicine Consultation Summary Letter (To Referring Clinician)

Letter Date: [Date]

Encounter Date: [Date] | [in-person / telehealth / records review]

Patient: [Full name], [DOB], [MRN if available]

To: [Referring clinician name, credentials, practice]

From: [Consulting clinician name, credentials, practice, contact info]

cc: [Other recipients] (Omit line if none)

Referral Question & Scope

[Opening acknowledgment and patient identification]. [Referral question as stated or addressed]. [Scope: one-time recommendations / shared co-management / ongoing integrative care]. (If PCP action is needed, frame as requests for collaboration.)

Executive Summary

Clinical Synopsis: [One sentence: age, key conditions, presenting syndrome, current status]

Key Findings:

• [Decision-relevant finding with brief interpretation]
• [Red flags ruled in or out]
• [Key lifestyle or environmental drivers]
• [Relevant medication or supplement exposures]

(Include 3–7 bullets; only decision-relevant information.)

Safety Considerations: [High-risk interactions, pregnancy/anticoagulation/surgery/organ dysfunction considerations, critical monitoring needs] (Omit this field entirely if no actionable safety issues exist.)

Recommendations

1. [Action: Start/Stop/Continue/Change/Order/Refer] [specific item] — [Owner: PCP / Patient / Integrative] — [Timeframe]. [One-clause rationale]. Monitor: [parameter, frequency]. (For supplements: include dose, form, duration, key risks, stop rules. Note if prerequisites needed before initiating.)
2. [Action] [specific item] — [Owner] — [Timeframe]. [Rationale]. Monitor: [parameter, frequency].
3. [Action] [specific item] — [Owner] — [Timeframe]. [Rationale]. Monitor: [parameter, frequency].

(Include 5–12 prioritized recommendations. Evidence strength labeling optional: strong/moderate/limited/expert consensus. Prefer third-party tested supplements.)

Requests for Referrer: [Specific actions, orders, or decisions requested from PCP with rationale and timeframe] (Omit if no specific requests.)

Supporting Clinical Detail

History: [Chief concern, timeframe, course, aggravating/relieving factors, prior workup, current therapies] (4–8 sentences. Include direct quotes only if they materially affect interpretation.)

Relevant Background: [Pertinent PMH] | [Current medications and supplements with verification status: patient-reported / bottles reviewed / pharmacy-reconciled] | [Allergies including botanicals/excipients] | [Relevant social/lifestyle factors: sleep, stress, diet, activity] (Include only items relevant to plan.)

Objective Data: [Vitals if measured] | [Targeted exam findings] | [Key labs/imaging with interpretation] (State "Physical exam not performed" if telehealth/records review. Summarize data; avoid pasting full panels.)

Assessment: [Working diagnoses and differentials using standard clinical terms with uncertainty language]. Integrative formulation: [Hypothesized biological, behavioral, psychological, or environmental contributors linked to specific evidence and corresponding interventions] (Label hypotheses as provisional, e.g., "may be contributing.")

Follow-up & Coordination

[Planned follow-up interval and visit type]. [How results will be reviewed; how urgent issues will be communicated]. [Responsibilities: who orders labs, tracks results, monitors supplement adverse effects]. [Contingencies if applicable: If X occurs, do Y, contact Z.] [Closing invitation for dialogue with direct clinician-to-clinician contact information.]

Signature:
[Clinician name], [Credentials]
[Role/Title], [Practice name]
[Direct phone] | [Secure fax/email]