Wellness & Prevention Visit Note (Naturopathic)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifiers]

Visit Type: Wellness/Prevention

Provider: [Provider name, credentials]

Source of History: [Patient / Other: specify source and relationship] (Note interpreter use if applicable.)

Visit Focus & Goals

[Statement that this is a prevention-focused visit; patient's primary prevention aims or health goals; any problem-oriented issues deferred for separate evaluation] (Write 1–3 sentences. Include a brief patient quote if goals or preferences were expressed directly.)

Subjective

Lifestyle: [Nutrition/dietary pattern; physical activity type, frequency, duration; sleep duration/quality; stress level and coping strategies; substance use with quantity/frequency] (Include enough detail to inform counseling. Note barriers, facilitators, and stage of change when stated. Omit domains not relevant to this patient.)

Relevant History: [Past medical, surgical, reproductive, and family history that affects risk stratification, screening timing, or counseling] (Include only items relevant to prevention; avoid exhaustive lists.)

Medications: [Current prescription and OTC medications with name, dose, frequency, indication, perceived benefit, and adherence] (If unknown, state "Unknown.")

Supplements/Herbal Products: [All current products with brand/constituents, dose, frequency, indication, perceived benefit, and adherence] (If none, state "None." If not assessed, state "Not assessed.")

Drug–Supplement Interaction Review: [Completed / Not completed; findings if applicable] (This is safety-critical content and must be documented. If not completed, state why.)

Allergies: [Drug, food, and environmental allergens with reaction type and severity] (If none known, state "NKDA." If not assessed, state "Not assessed.")

Screening & Immunization Status: [Completed screenings with dates and results; next due dates; immunization history; refusals or deferrals with patient reasoning] (Label patient-reported results as such.)

Objective

Vitals: [BP, HR, weight/BMI, waist circumference, and other relevant measures; trends if available] (If vitals not obtained, state reason.)

Exam: [Pertinent findings by system relevant to prevention focus] (If limited or deferred, state reason.)

Data Reviewed: [Recent labs, imaging, outside records, risk calculators, and screening tool results with dates] (Label patient-reported results as such.)

Assessment

[One-sentence wellness summary synthesizing key risk and protective factors and overall prevention direction]

• [Prioritized risk factor or prevention gap with supporting data]
• [Additional risk factors or gaps as applicable]

(Frame as risk assessment rather than symptom differential. If findings require diagnostic workup, note that a problem-oriented evaluation follows.)

Plan — Personalized Prevention Plan

• Lifestyle Counseling: [Specific actions agreed for nutrition, physical activity, sleep, stress management, and/or substance use; counseling provided; barriers addressed; patient readiness] (Use SMART goal format where applicable.)
• Supplement/Herbal Recommendations: [Product, dose, frequency, intended role, evidence basis, planned duration, monitoring parameters, and stop-rules; statement that interactions/contraindications were reviewed] (For existing supplements: continue/modify/discontinue with rationale. Avoid implying FDA approval for disease treatment. Omit if no supplement changes.)
• Screening Schedule: [Tests due with timing; orders placed today; shared decision-making for preference-sensitive screenings]
• Immunizations: [Vaccines due; administered/declined with reasoning] (Omit if no vaccines applicable.)
• Referrals: [Referrals placed with purpose] (Omit if none.)
• Follow-Up: [Timing; what will be reassessed; thresholds for earlier contact]

Problem-Oriented Addendum

(Include only if a separately identifiable medical issue was evaluated beyond routine prevention counseling. Omit entirely if no problem-oriented evaluation occurred.)

Problem: [Chief concern with onset, duration, course, associated symptoms]

Exam/Data: [Focused findings relevant to the problem]

Assessment: [Diagnosis or differential]

Plan: [Diagnostics, treatments, patient instructions, return precautions, problem-specific follow-up]