Women's Health/Hormonal Visit Note (Naturopathic)

Date/Time: [Date and time of encounter]

Visit Type: [new / established]; [problem-focused / follow-up]

Setting: [in-person / telehealth: video / telehealth: phone] (If telehealth, note patient location and that identity verification and consent were obtained.)

Clinician: [Name, credentials]

Reason for Visit: [Primary concern(s)]

Subjective

Chief Concern & HPI: [Chief concern in patient's words when helpful] [Narrative HPI covering onset, trajectory, severity, functional impact, prior treatments and responses, patient goals/preferences]

• [Symptom inventory — menstrual/cycle] (Include only if relevant: cycle-related pain, bleeding changes, PMS/PMDD features, ovulatory signs, intermenstrual bleeding.)
• [Symptom inventory — vasomotor/sleep/mood] (Include only if relevant: hot flashes/night sweats, sleep quality, mood/anxiety/cognitive changes.)
• [Symptom inventory — genitourinary] (Include only if relevant: vaginal dryness, dyspareunia, urinary symptoms.)
• [Symptom inventory — hyperandrogen] (Include only if relevant: hirsutism, acne, alopecia.)

Red-flag symptoms: [postmenopausal bleeding / syncope / severe pelvic pain / rapidly progressive symptoms / none reported] (Document only items explicitly asked or volunteered.)

Reproductive & Relevant Medical History

LMP: [Date / unknown]

Cycle pattern: [Length, regularity, flow]

Obstetric history: [G/P; relevant complications]

Contraception/pregnancy intention: [Current method; intentions]

Menopause status: [Premenopausal / Perimenopausal / Postmenopausal] (Note how determined if applicable.)

Relevant PMH: [VTE, migraine with aura, hypertension, liver disease, cancer history, thyroid disease] (List only relevant items.)

Current medications: [Name, dose, frequency, indication]

Supplements/botanicals: [Name, dose, frequency, purpose for each]

Allergies: [Drug/food allergies and reactions]

Hormone exposure history: [Prior/current hormonal therapies, adverse events, reasons stopped]

Lifestyle factors: [Sleep; nutrition pattern; exercise; stress load; caffeine/alcohol/nicotine use]

Objective

Vitals: [BP, HR, weight/BMI as relevant]

Exam: [General, thyroid, abdomen, skin/hair as indicated] (If breast or pelvic exam performed, document indication, chaperone status, and findings. If deferred, note reason.)

Data reviewed: [Prior labs with dates, imaging, outside records] (Note what was reviewed and how it influenced decisions.)

Assessment

1. [Problem 1]: [Working diagnosis or symptom-based problem] — [new / stable / worsening]

   • [Key supporting data: 2–4 items]
   • [Differential diagnosis] (Include only if uncertain; acknowledge level of uncertainty.)
   • [Safety considerations: pregnancy possibility, contraindications, red flags]

2. [Problem 2]: [Working diagnosis or symptom-based problem] — [new / stable / worsening]

   • [Key supporting data]
   • [Differential diagnosis] (If applicable.)
   • [Safety considerations]

(Add additional problems as needed, in order of clinical priority.)

Plan

[Problem 1]: [Diagnosis or symptom focus]

Phase 0 (Safety/Rule-outs): [Pregnancy exclusion if relevant] [Red-flag evaluation/referral] [Contraindication screening before hormones or high-risk therapy]

Phase 1 (Foundations): [Sleep, nutrition, movement, stress regulation, trigger tracking recommendations with timeline of 2–6 weeks]

Phase 2 (Targeted Therapeutics):

• [Supplement/botanical: name, dose, frequency, duration, purpose, monitoring plan]
• [Prescription therapy if any: name, dose, frequency, monitoring plan]
• (For therapies with limited evidence, document that uncertainty was discussed.)

Hormone therapy (if initiated): [Indication] [Contraindication screening documented] [Product: name, route, dose, frequency] [Counseling: benefits, side effects, warning signs] [Follow-up plan] (If compounded, document rationale and counseling vs FDA-approved options.)

Phase 3 (Escalation/Referral): [Criteria for escalation, specialty referral, or advanced workup]

Testing ordered: [Test name] — [Clinical question] — [How results will change management]

Preventive screening: [Cervical, breast, bone density, depression, IPV as addressed] (Note briefly if discussed or ordered.)

Return precautions: [Specific red flags warranting earlier contact]

Follow-up: [Timeline] [What will be reassessed]

(Repeat plan sections for additional problems as needed. Document missing clinically important information as "unknown" rather than omitting. Do not document findings for exams not performed.)