Integrative Medicine Comprehensive Initial Consultation Note

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time] (Include only if tracking time for billing.)

Location/Modality: [Clinic name or telehealth; in-person / video / phone]

Clinician: [Name, credentials]

Participants: [Patient; others present such as family, caregiver, interpreter]

Referral Source: [Self-referral / Referring clinician name / Service]

Reason for Referral: [Reason for referral]

Primary Care Clinician: [Name or practice]

Sources of History: [Patient / Caregiver / Records reviewed / Other]

Chief Concern

[Primary concern(s) and what patient seeks from integrative medicine; may include brief patient quote] (One to two concise lines using person-centered, non-stigmatizing language.)

Visit Agenda and Goals

• [Top 1–3 priorities for today's visit]
• [Longer-term functional or quality-of-life goals]
• [Values or life priorities that inform care preferences]

(If not obtained, state reason.)

Records Reviewed

Reviewed prior to/during visit:

• [External clinical notes with dates]
• [Prior labs and imaging with dates]
• [Medication list source and last reconciliation date]
• [Prior integrative or complementary treatments and documented outcomes]

Patient-reported prior care (not independently verified):

• [Treatments or evaluations patient reports, with approximate dates and perceived outcomes]

History of Present Illness

[Narrative of presenting concern(s): onset, timing, duration, severity, course, triggers, relievers, prior evaluations and treatments with response, impact on function, and patient's understanding of likely contributors. Include assessed red flags with pertinent positives and negatives.] (Write as a cohesive paragraph; clearly distinguish patient perspectives from clinician impressions.)

Nutrition

• [Typical dietary pattern and meal timing]
• [Hydration, caffeine, and alcohol intake]
• [Special diets tried and outcomes]
• [Food access or insecurity concerns]

(Omit subsection if not assessed, or state "Not obtained" with brief reason.)

Digestion/Elimination

• [Appetite, reflux, nausea]
• [Bowel pattern: frequency, consistency, urgency]
• [Bloating, gas, food associations]
• [Relevant prior GI workup and results]

Sleep

• [Schedule, duration, quality, awakenings]
• [Snoring or apnea symptoms]
• [Insomnia drivers]
• [Current sleep aids and effectiveness]

Stress and Mental Health

• [Current stressors and coping strategies]
• [Mood, anxiety, and cognitive symptoms]
• [Mind-body practices tried and response]
• [Safety screening: No risk identified / Risk identified – details]

Physical Activity

• [Baseline activity level and sedentary time]
• [Limitations and pain triggers]
• [Prior PT or exercise programs and response]

Social Supports

• [Household composition and caregiver responsibilities]
• [Support network and community resources]
• [Work or school demands]

Environment

• [Housing stability and conditions]
• [Occupational or hobby exposures]
• [Tobacco exposure]
• [Sleep environment concerns]

Meaning and Purpose

• [Spiritual or cultural practices if patient wishes to discuss]
• [Alignment of health and life goals]
• [Cultural preferences affecting care]

Reproductive Health (Include only if clinically relevant.)

• [Menstrual history / menopause symptoms]
• [Contraception]
• [Sexual function and concerns]

Substance Use

• [Tobacco/nicotine: pattern and quantity]
• [Alcohol: pattern and quantity]
• [Cannabis: pattern and quantity]
• [Other substances: pattern and quantity]

(Use neutral, non-judgmental language; document readiness for change when relevant.)

Past History

Past Medical History: [Major chronic conditions and hospitalizations]

Past Surgical History: [Surgeries and approximate dates]

Psychiatric History: [Prior diagnoses, treatments, hospitalizations] (Include only if relevant.)

Medications, Supplements, and Integrative Therapies

• Prescription medications: [Name – dose – frequency – indication – adherence; note adverse effects and perceived benefits]
• OTC medications: [Name – dose – frequency – indication]
• Vitamins/minerals/herbals/supplements: [Product – dose – frequency – brand if relevant – indication – perceived benefit/side effects]
• Complementary therapies currently used: [e.g., acupuncture, chiropractic, massage, mind-body practices – frequency – outcomes]
• Interactions/contraindications: [Clinically significant issues affecting the plan]

Allergies and Adverse Reactions

• Medications: [Agent – reaction type]
• Foods: [Agent – IgE allergy vs intolerance when known]
• Supplements: [Agent – reaction]

Family History

• [Cardiometabolic disease in first-degree relatives]
• [Cancer patterns]
• [Autoimmune conditions]
• [Psychiatric or substance use disorders]

Social History

• [Occupation and schedule]
• [Living situation]
• [Financial or transportation barriers]
• [Safety concerns]

(Include only elements relevant to this patient's care.)

Review of Systems

• [Targeted systems reviewed that inform differential; include pertinent positives and negatives]

(Avoid exhaustive autopopulated negatives. State "ROS otherwise negative as reviewed" only if a broad review was performed. Omit section if ROS not performed.)

Objective

Vitals: [BP, HR, RR, Temp, SpO2, height, weight, BMI] (If not obtained, state reason.)

Physical Examination (Include only systems examined; document pertinent positives and negatives influencing assessment.)

• General: [Appearance, level of distress]
• HEENT: [Eyes, ears, nose, throat, thyroid, oral health]
• Cardiopulmonary: [Heart and lung findings]
• Abdomen: [Inspection, auscultation, palpation findings]
• MSK: [Range of motion, strength, tenderness]
• Neuro: [Mental status, focal findings, gait]
• Skin: [Rashes, lesions]

(If exam not performed, state reason.)

Diagnostic Data Reviewed

• [Labs with dates and concise interpretation]
• [Imaging with dates and concise interpretation]
• [Prior studies (e.g., sleep study, endoscopy, cardiac testing) with key results]

Screening Tools (Include only if administered.)

• [Tool name – score – date – clinical interpretation]

Assessment

[Summary statement synthesizing: key symptoms and duration, pertinent lifestyle and history elements, exam and lab findings, psychosocial context, and patient goals] (Use neutral language; distinguish facts from hypotheses.)

[Problem 1]: [Working diagnosis or symptom cluster] – [confirmed / suspected / symptom cluster]

• Differential diagnosis: [Biomedical possibilities; lifestyle/behavioral contributors (sleep, stress, nutrition, activity); psychosocial contributors; environmental/occupational factors; medication/supplement contributors] (Label speculative items as hypotheses.)
• Severity and functional impact: [Severity; impact on daily activities; safety considerations]
• Supporting findings: [Pertinent exam, labs, imaging]

[Problem 2]: [Working diagnosis or symptom cluster] – [confirmed / suspected / symptom cluster]

(Add additional problems as needed following the same structure.)

Plan

(Organize by problem; include only relevant subheadings for each problem.)

[Problem 1]: [Plan title]

Diagnostics and Monitoring: [Labs or imaging with clinical question; symptom tracking plan; safety monitoring]

Conventional Management: [Medication changes with dose and rationale; referrals; coordination with other clinicians]

Nutrition: [Specific recommendations linked to problem; 1–3 actionable steps; barriers addressed; dietitian referral if warranted]

Sleep: [Behavioral targets; evaluation for sleep disorders if indicated; safety documentation for sleep aids]

Physical Activity: [Type, frequency, intensity, modifications; PT referral if needed]

Stress and Mind-Body: [Practices recommended; therapy/program referrals; safety plan if risk identified]

Supplements: [Indication and goal; product form and dose; expected timeframe; contraindications and interactions; quality considerations] (Include only if recommending supplements; note supplements are adjunctive to evidence-based treatment when applicable.)

Shared Decision-Making: [Options discussed including watchful waiting; benefits and risks reviewed; patient preferences and selected plan]

Follow-Up: [Interval; what will be reviewed; return precautions; task ownership (patient / clinician / care team)]

[Problem 2]: [Plan title]

(Repeat subheadings as applicable for each additional problem.)

Care Coordination

• [Communications with other clinicians]
• [Records requested or shared]
• [Work or school notes provided]

(Omit section if no care coordination activities.)

Billing Documentation

(Optional – include one of the following if needed.)

MDM Support: [Number and complexity of problems addressed; data reviewed/ordered; risk of management]

Time Support: [Total clinician time on date of service; brief activity description]

Signature

[Clinician name and credentials]

[Date and time of signature]

(For corrections or addenda, label clearly with current date and time; do not overwrite original content.)

Missing Information Conventions: Use "Unknown (patient unsure)," "Not obtained (reason)," "Patient-reported only," or "Outside records not available" when applicable. Omit sections entirely if not assessed and not clinically necessary.