Lifestyle & Nutrition Counseling Note (Integrative Medicine)

Date/Time: [Date and time of encounter]

Patient: [Name; identifiers as used locally]

Provider: [Name, credentials]

Visit Type: [initial / follow-up]; [in-person / telehealth]

Chief Concern & Agenda

[Primary concern in patient's words] [Patient-stated goals for today] [Clinician framing of scope for this visit] (Keep to 2–4 lines; present as brief narrative or concise labeled fields.)

Lifestyle History

Context/Trajectory: [Onset and context of lifestyle concerns; precipitating factors; impact on function and quality of life] (For follow-ups: interval changes, adherence, and progress since last visit.)

Prior Efforts & Response: [Previous strategies tried; what helped/didn't; barriers encountered] (For follow-ups: facilitators and solutions attempted.)

Priorities & Constraints: [Patient priorities; cultural/food traditions; budget; time; cooking facilities/access] (Include only if relevant.)

Nutrition: [Dietary pattern: meal timing/structure; food quality indicators; beverages; symptoms related to eating; food access] (Attribute as patient-reported or device/lab-supported; do not infer adherence.)

Physical Activity: [Baseline frequency, duration, types; sedentary time; functional limitations; safety considerations]

Sleep: [Schedule/regularity; quantity/quality; insomnia or sleep-disordered breathing symptoms; sleep environment]

Stress & Coping: [Major stressors; coping strategies; mood/anxiety screening results if performed; social support]

Substances/Medications/Supplements: [Alcohol; nicotine; medications affecting weight/appetite/sleep; supplements/botanicals with doses]

Pertinent Medical History: [Conditions, procedures, or family history directly informing the plan]

(Omit domains not relevant to this visit.)

Objective

Vitals/Anthropometrics: [Weight, BMI, BP, HR, waist circumference as relevant] (If unavailable, state why.)

Exam: [Focused findings relevant to safety/decision-making] (Omit autopopulated normals.)

Data Reviewed: [Pertinent labs with dates, device/wearable data, screening tool scores with interpretation]

Assessment

[1–2 sentence clinical synthesis linking patient goals, key findings, and main drivers]

1. [Problem 1]: [Diagnosis/impression; current status]. [Contributing lifestyle factors]. [Readiness and key barriers if relevant to plan.]
2. [Problem 2]: [As above] (Include additional problems only if applicable.)

Plan

(Organize by problem or lifestyle domain; link each action to documented problems. Use shared decision-making language.)

Interventions:

• Nutrition: [Strategy with concrete behavioral steps; quantities/timing if applicable]
• Physical Activity: [FITT-P prescription; safety guidance]
• Sleep: [Schedule targets; behavioral modifications]
• Stress Management: [Practices prescribed; frequency/duration]
• Supplements/Integrative Therapies: [Product; dose; duration; safety counseling; monitoring/stop rules]

(Omit domains not addressed.)

Goals (SMART):

• [Goal 1: Specific behavior; baseline → target; timeframe; measurement method]
• [Goal 2: Specific behavior; baseline → target; timeframe; measurement method]
• [Additional goals as applicable, 2–4 total]

Counseling Approach: [Framework used: motivational interviewing / change ruler / Five A's / other]; [barriers/facilitators discussed]; [patient confidence 0–10 or stage of change]

Orders/Referrals: [Labs ordered with indications]; [referrals: dietitian, health coach, behavioral health, sleep medicine, etc.]

Follow-up: [Interval and modality]; [what will be reviewed]; [red flags/escalation criteria warranting earlier contact]

(If a safety-relevant element was not assessed, note "not assessed" with reason. Document total encounter time if needed for billing.)