Naturopathic Consultation Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Naturopathic Consultation Note

Patient Identification: [Patient name, age, gender, presenting complaint or reason for visit]

History of Present Illness:
[Description of presenting symptoms, onset, duration, progression, aggravating/relieving factors, previous treatments, and impact on daily life]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Previous surgeries]
- [Hospitalizations]

Medications & Supplements:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Supplement name, dose, frequency]

Allergies:
(hyphenated list)
- [Drug, food, environmental allergies]
- [Reaction type]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Dietary habits: typical intake, restrictions, preferences]
- [Physical activity: type, frequency, duration]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Stressors: recent or ongoing]

Review of Systems:
(hyphenated list)
- [General: energy, sleep, weight changes]
- [Other systems as relevant: e.g., cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, etc.]

Investigations:
(hyphenated list)
- [Laboratory or imaging results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment:
(hyphenated list)
- [Diagnosis or clinical impression]
- [Contributing factors or underlying causes]

Plan:
(hyphenated list)
- [Lifestyle recommendations: diet, exercise, sleep, stress management]
- [Naturopathic therapies: herbal, nutritional, physical, mind-body]
- [Supplements prescribed]
- [Further investigations planned or ordered]
- [Referrals to other providers]
- [Patient education and counselling]
- [Follow up plan]
- [Return precautions]