Nutrition & Lifestyle Counseling Note (Traditional Chinese Medicine)

Date of Service: [Date]

Patient: [Patient name or identifier]

Provider: [Provider name, credentials]

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

Chief Concern & Counseling Focus

Patient words: [Patient-stated reason for visit] (Use quotation marks only if directly quoted.)
Today's focus: [Topics addressed this visit]
Deferred items: [Clinically relevant items deferred with brief reason] (Omit if none.)

Subjective

[History of present concern: onset, course, triggers/modifiers, functional impact]

Patient Goals: [Desired outcomes and priorities in patient's words] (Omit if not discussed.)

Diet Pattern: [Meal timing/structure; temperature preferences; fluids; caffeine/alcohol; trigger foods] (State "Not assessed" if omission could be misread as normal.)

Lifestyle Pattern: [Sleep schedule/quality; stress drivers and coping; movement/exercise; thermal/environmental sensitivities] (State "Not assessed" if omission could be misread as normal.)

Relevant History: [Pertinent medical conditions; current care team; past interventions tried] (Include only items relevant to counseling.)

Medications/Supplements: [Active medications and supplements relevant to counseling]

Allergies: [Food and medication allergies with reaction types] (If not reviewed, state "Not reviewed" with reason.)

Objective

• Vitals/Anthropometrics: [Measured weight, BMI, or other relevant metrics] (Include only if obtained or specifically reviewed this visit.)
• TCM Exam: [Tongue: body color, shape, coat, moisture, marks; Pulse: rate, depth, qualities] (For telehealth, note limitations. If not performed, state "Not performed" with reason.)
• Pertinent Data: [Relevant labs/diagnostics reviewed with dates] (Omit if none reviewed.)

Assessment

[One-line synthesis: patient context, key symptoms, and primary drivers]

TCM Pattern(s):

• Primary: [Pattern name] — [Supporting evidence: salient symptoms, tongue/pulse findings, diet/lifestyle contributors]
• Secondary: [Pattern name] — [Supporting evidence] (Omit if none.)
• Uncertain/competing patterns: [Brief differential and data needed to clarify] (Omit if not applicable.)

Nutrition Assessment: [Key diet patterns, facilitators/barriers, and constraints affecting recommendations]

Plan

Shared decision-making: [Options discussed; patient preferences using "patient chose" or "patient prefers"]

Diet Strategy:

• [Thermal approach and preparation methods]
• [Meal timing/structure adjustments]
• [Foods to emphasize and foods to limit; substitutions aligned to preferences/budget]
• [Hydration guidance: type, timing, temperature]

Lifestyle Strategy:

• [Sleep plan: schedule targets and wind-down routine]
• [Stress regulation: specific techniques, frequency, timing]
• [Movement plan: type, frequency, minimum viable commitment]

Goals (1–3):

• [Goal: specific behavior + frequency; Start date; Review date; Anticipated barriers; Coping plan]
• [Additional goal if applicable]
• [Additional goal if applicable]

Self-Monitoring: [What patient will track and format/method]

Follow-Up: [Interval; modality; what to bring; criteria for earlier contact or medical evaluation]

Safety/Coordination: [Contraindications/precautions; referrals or coordination with care team] (Include if recommendations could conflict with existing medical care.)

Education Provided: [Materials given and comprehension verification method]

(Omit sections with no encounter-specific content. TCM patterns must include explicit supporting evidence. Do not infer adherence or agreement—document only what was stated or observed.)