Naturopathic New Patient Comprehensive Intake Note

Date: [Date of service]

Patient Name: [Full name]

DOB: [Date of birth]

Referral Source: [Self / Provider name / Other]

History obtained from: [Patient / caregiver / prior records / interpreter]; Reliability: [good / fair / limited]

Informed Consent: [Consent status] (If obtained today, note that scope of practice, qualifications, risks, benefits, and limitations were discussed. If on file, state "Informed consent on file; reviewed today." If not obtained, document reason.)

Subjective

Chief Concerns and Goals

• [Chief concern in patient's words] — [Patient-stated goals and what improvement would look like] (Note time-sensitive or safety considerations if present: pregnancy intent, red-flag symptoms, occupational requirements.)
• [Additional concerns as needed]

History of Present Illness

(Write a narrative paragraph for each chief concern.)

[Concern 1]: [Onset and timeline; symptom quality and severity; pattern and variability; aggravating and alleviating factors including dietary triggers; associated symptoms and pertinent negatives; functional impact on daily life; prior evaluations and treatments including supplements and alternative therapies with responses.] (Include brief patient quotes when clinically meaningful, then translate to clinical descriptors. Document uncertainty about chronology if present.)

[Concern 2]: [Narrative as above]

Past Medical History

• [Chronic conditions with approximate dates of diagnosis]
• [Major acute illnesses, hospitalizations, surgeries with approximate dates]
• [OB/GYN history when relevant: menstrual pattern, pregnancies and outcomes, menopausal status, fertility goals]

Allergies and Adverse Reactions

• [Allergen/substance]: [Reaction type] — [True allergy / intolerance / side effect]
• (If none: "No known allergies." If not assessed: "Not assessed today." If unknown: "Unknown (patient unsure).")

Medication and Supplement Reconciliation

(List reviewed and updated today. Include all prescriptions, OTCs, supplements, botanicals, hormones, compounded products, cannabis/CBD.)

• [Product name and formulation]: [Dose] [Route] [Frequency]; Purpose: [indication]; Duration: [start date or length of use]; Adherence: [consistent / intermittent / unsure]; Source: [prescriber or recommender]; Response: [benefits and/or side effects]
• (If discrepancies or uncertainty exist, document the limitation explicitly.)
• (If patient takes nothing: "No current medications, supplements, or OTC products.")

Family History

• [Condition] — [Relationship] — [Age of onset if known]
• (Focus on first-degree relatives: cardiometabolic disease, cancer, autoimmune conditions, thyroid disease, GI conditions, psychiatric disorders, substance use. If unknown or adopted, state explicitly.)

Social and Lifestyle History

• Living situation: [Household composition, caregiving responsibilities, safety]
• Occupation: [Type of work, schedule, relevant exposures, ergonomic factors]
• Nutrition: [Eating pattern and timing; dietary approach or restrictions; protein and fiber adequacy; processed food and sugar intake; caffeine; alcohol; patient-reported food sensitivities; food access and cooking capacity]
• Physical activity: [Type, frequency, duration; limitations; goals]
• Sleep: [Schedule; quality; onset or maintenance difficulties; snoring or apnea symptoms]
• Stress and coping: [Major stressors; resilience factors; coping practices]
• Substance use: Tobacco/nicotine: [status]; Alcohol: [quantity and frequency]; Cannabis: [status]; Other: [status] (Use "Not assessed today" or "Unknown (patient unsure)" if applicable.)
• Environmental exposures: [Occupational chemicals; mold or water damage; air quality; well water; tick exposure; recent travel; pets]
• Reproductive status: [Pregnancy possibility / intent; contraception; lactation] (Include when clinically relevant.)

Review of Systems

[Pertinent positives and negatives relevant to chief concerns] (If comprehensive ROS completed via intake form and reviewed, state that and highlight only significant findings. Avoid exhaustive normal checklists.)

Objective

Vitals

BP: [value] | HR: [value] | RR: [value] | Temp: [value] | SpO2: [value] | Ht: [value] | Wt: [value] | BMI: [value]

(If vitals not obtained, document reason.)

Physical Examination

[Problem-focused / Comprehensive] examination performed.

• General: [Appearance, distress level, nourishment, affect]
• HEENT: [Findings]
• Neck: [Findings]
• Cardiovascular: [Findings]
• Respiratory: [Findings]
• Abdomen: [Findings]
• MSK: [Findings]
• Neurological: [Findings]
• Skin: [Findings]
• Psychiatric: [Mood, affect, thought process]
• (Include only systems examined. Add or remove as relevant.)

Results Reviewed

• [Lab/imaging/record type] — [Date] — [Key findings]
• (Distinguish results reviewed today from tests ordered or pending.)

Assessment

[Brief integrative summary synthesizing chief concerns, relevant history, exam findings, and lifestyle factors, describing how they interrelate]

Problem List

(Order by clinical risk and urgency, then symptom burden, then optimization goals.)

1. [Problem/diagnosis]

• Status: [new / chronic / acute on chronic]; [controlled / uncontrolled / improving / worsening / stable]
• Supporting evidence: [Pertinent history, exam, and objective findings]
• Differential/rule-outs: [If applicable]
• Naturopathic considerations: [Potential contributing factors or patterns] (Label as hypotheses or considerations when not established diagnoses.)
• Red flags: [Concerning features if present, otherwise omit]

2. [Problem/diagnosis]

• Status: [status]
• Supporting evidence: [evidence]
• Differential/rule-outs: [if applicable]
• Naturopathic considerations: [considerations]

(Add additional problems as needed.)

Plan

(Organize by problem, matching Assessment order. Be specific and measurable.)

1. [Problem/diagnosis]

• Diagnostics: [Tests ordered and rationale; clinical decisions dependent on results]
• Therapeutic interventions:
  • Nutrition: [Specific changes and targets]
  • Supplements/botanicals: [Product name] — [Dose] [Frequency] for [Duration] — Purpose: [indication] (Note interactions, contraindications, or pregnancy/lactation considerations if relevant.)
  • Lifestyle: [Physical activity, sleep, stress management targets — specific and measurable]
• Patient education: [Risks, benefits, alternatives discussed; patient preference]
• Referrals: [PCP / specialist / behavioral health / other] (Omit if none.)
• Follow-up: [Timing]; [What will be reassessed]; [Success criteria]; [Lab recheck interval if applicable]
• Return precautions: [Symptoms prompting urgent or emergency evaluation] (Include when clinically indicated.)

2. [Problem/diagnosis]

• Diagnostics: [If applicable]
• Therapeutic interventions: [Nutrition, supplements, lifestyle as relevant]
• Patient education: [Discussion summary]
• Follow-up: [Timing and reassessment plan]

(Add additional problem-specific plans as needed.)

Billing

Total time: [minutes] on date of service (If billing by time. Otherwise omit section or note MDM-based billing.)