Supplement/Herbal Therapy Plan (Naturopathic)

Date/Time: [Date and time of documentation]

Patient: [Full name]  |  DOB: [MM/DD/YYYY]

Provider: [Name, credentials]  |  Setting: [in-person / telehealth / telephone]

Note Type: Supplement/Herbal Therapy Plan

Indication & Goals

[Clinical indication or working diagnosis] [Measurable goals with target symptom scale, functional outcome, or lab range if applicable] [Timeframe for reassessment]

Current Regimen & Safety Review

Medications/Supplements: [List current prescription medications, OTC agents, and supplements with doses; use "dose unknown—patient to verify" for unknowns rather than omitting; note anticoagulant/antiplatelet use explicitly]

Allergies: [Drug allergies, supplement reactions, and relevant food/excipient allergies (soy, shellfish, gelatin, etc.) that affect product selection; document "NKDA reported" or "allergy history not obtained" explicitly]

Safety Factors: [Relevant risk factors only: pregnancy/lactation status, renal/hepatic function if applicable, bleeding risk, upcoming procedures, contraindicated diagnoses for proposed supplements; note unknowns requiring clarification before initiation]

Interaction Screening: [Scope screened: drug–herb, herb–herb] using [tool/source] on [date]. [Disposition: no major interactions identified / potential interaction(s) identified—see Supplement Plan / screening incomplete—do not state "no interactions" until medication list reconciled] (If proceeding despite potential interaction, document rationale.)

Supplement Plan

(Repeat block for each supplement. Do not finalize if product identity or safety information is incomplete.)

Product [#]: [Common name; Latin binomial and plant part if botanical; formulation type; standardization marker if applicable]
Brand/Source: [Specific brand or "any USP-verified/third-party tested equivalent"]; [strength per unit and key actives per serving]
Indication: [Link to clinical indication]; [evidence supports modest benefit / evidence limited; trial justified given low risk and patient preference]
Dosing: [Amount in mg/mcg/IU], [frequency], [timing: with meals/empty stomach/bedtime], [route]; [titration if applicable]; [planned duration or reassessment interval]
Precautions: [Key contraindications; stop parameters; identified interactions with management plan]
Status: [initiated / continued / adjusted / held / discontinued / pending verification]   Start: [date]   Review: [date]

Regulatory status: Dietary supplements are regulated differently than prescription drugs and are not FDA-approved to diagnose, treat, cure, or prevent disease.

Monitoring & Follow-up

Tracking: [Target symptoms and measurement method; expected time to effect]
Watch for: [Common adverse effects]; Red flags: [Serious symptoms requiring urgent evaluation]
Labs: [Baseline and follow-up labs if indicated, with timing]
Follow-up: [Timeframe and modality]; Early return/stop criteria: [Triggers for earlier evaluation or discontinuation]

Patient Counseling

• [Discussed expected benefits, limitations, and realistic timelines]
• [Reviewed common side effects and red-flag symptoms]
• [Advised to inform all healthcare providers about supplement use]
• [When to stop: pregnancy, new medications, upcoming procedures, adverse symptoms]
• [Patient verbalized understanding and agreement with plan]

Provider Signature: [Electronic signature / typed name, credentials]   Date/Time: [Date and time]