Session Info

Date:

Visit type:

Initial

Follow-up

Telehealth

Duration (min):

CPT / billing code:

Subjective — Interval Update

Changes since last visit:

Symptom score trend:

New concerns:

Patient priorities:

Overall interval change:

Improved

Stable

Worsened

Mixed

Symptom Tracking (MSQ)

Not Provided Score

1. Headaches

NoneMildModerateSevereVery severe

2. Faintness

NoneMildModerateSevereVery severe

3. Dizziness

NoneMildModerateSevereVery severe

4. Insomnia

NoneMildModerateSevereVery severe

1. Watery or itchy eyes

NoneMildModerateSevereVery severe

2. Swollen, reddened or sticky eyelids

NoneMildModerateSevereVery severe

3. Bags or dark circles under eyes

NoneMildModerateSevereVery severe

4. Blurred or tunnel vision

NoneMildModerateSevereVery severe

1. Itchy ears

NoneMildModerateSevereVery severe

2. Earaches, ear infections

NoneMildModerateSevereVery severe

3. Drainage from ear

NoneMildModerateSevereVery severe

4. Ringing in ears, hearing loss

NoneMildModerateSevereVery severe

1. Stuffy nose

NoneMildModerateSevereVery severe

2. Sinus problems

NoneMildModerateSevereVery severe

3. Hay fever

NoneMildModerateSevereVery severe

4. Sneezing attacks

NoneMildModerateSevereVery severe

5. Excessive mucus formation

NoneMildModerateSevereVery severe

1. Chronic coughing

NoneMildModerateSevereVery severe

2. Gagging, frequent need to clear throat

NoneMildModerateSevereVery severe

3. Sore throat, hoarseness, loss of voice

NoneMildModerateSevereVery severe

4. Swollen or discolored tongue, gums, lips

NoneMildModerateSevereVery severe

5. Canker sores

NoneMildModerateSevereVery severe

1. Acne

NoneMildModerateSevereVery severe

2. Hives, rashes, dry skin

NoneMildModerateSevereVery severe

3. Hair loss

NoneMildModerateSevereVery severe

4. Flushing, hot flashes

NoneMildModerateSevereVery severe

5. Excessive sweating

NoneMildModerateSevereVery severe

1. Irregular or skipped heartbeat

NoneMildModerateSevereVery severe

2. Rapid or pounding heartbeat

NoneMildModerateSevereVery severe

3. Chest pain

NoneMildModerateSevereVery severe

1. Chest congestion

NoneMildModerateSevereVery severe

2. Asthma, bronchitis

NoneMildModerateSevereVery severe

3. Shortness of breath

NoneMildModerateSevereVery severe

4. Difficulty breathing

NoneMildModerateSevereVery severe

1. Nausea, vomiting

NoneMildModerateSevereVery severe

2. Diarrhea

NoneMildModerateSevereVery severe

3. Constipation

NoneMildModerateSevereVery severe

4. Bloated feeling

NoneMildModerateSevereVery severe

5. Belching, passing gas

NoneMildModerateSevereVery severe

6. Heartburn

NoneMildModerateSevereVery severe

7. Intestinal/stomach pain

NoneMildModerateSevereVery severe

1. Pain or aches in joints

NoneMildModerateSevereVery severe

2. Arthritis

NoneMildModerateSevereVery severe

3. Stiffness or limitation of movement

NoneMildModerateSevereVery severe

4. Pain or aches in muscles

NoneMildModerateSevereVery severe

5. Feeling of weakness or tiredness

NoneMildModerateSevereVery severe

1. Binge eating/drinking

NoneMildModerateSevereVery severe

2. Craving certain foods

NoneMildModerateSevereVery severe

3. Excessive weight

NoneMildModerateSevereVery severe

4. Compulsive eating

NoneMildModerateSevereVery severe

5. Water retention

NoneMildModerateSevereVery severe

6. Underweight

NoneMildModerateSevereVery severe

1. Fatigue, sluggishness

NoneMildModerateSevereVery severe

2. Apathy, lethargy

NoneMildModerateSevereVery severe

3. Hyperactivity

NoneMildModerateSevereVery severe

4. Restlessness

NoneMildModerateSevereVery severe

1. Poor memory

NoneMildModerateSevereVery severe

2. Confusion, poor comprehension

NoneMildModerateSevereVery severe

3. Poor concentration

NoneMildModerateSevereVery severe

4. Poor physical coordination

NoneMildModerateSevereVery severe

5. Difficulty in making decisions

NoneMildModerateSevereVery severe

6. Stuttering or stammering

NoneMildModerateSevereVery severe

7. Slurred speech

NoneMildModerateSevereVery severe

8. Learning disabilities

NoneMildModerateSevereVery severe

1. Mood swings

NoneMildModerateSevereVery severe

2. Anxiety, fear, nervousness

NoneMildModerateSevereVery severe

3. Anger, irritability, aggressiveness

NoneMildModerateSevereVery severe

4. Depression

NoneMildModerateSevereVery severe

1. Frequent illness

NoneMildModerateSevereVery severe

2. Frequent or urgent urination

NoneMildModerateSevereVery severe

3. Genital itch or discharge

NoneMildModerateSevereVery severe

Objective

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Exam highlights:

Labs Reviewed

Report details

Panel Kind

Blood

Vendor / Lab

e.g. Lifelabs, Dynacare

Panel Name

e.g. CBC, Lipid Panel

Collection Date

YYYY-MM-DD

Result Date

YYYY-MM-DD

Specimen Type

Search specimen...

Panel Status

Final

Source Document

No source document attached

Tests

Tests List Add test

No tests entered yet. Add a test to capture a value and reference interval.

Assessment — Response Since Last Visit

Adherence:

Full adherence

Partial adherence

Missed doses

Stopped

Tolerance:

Well tolerated

Mild adverse effect

Adverse effect — see note

Adherence / missed doses:

Adverse effects:

Goal progress (% or patient rating):

New diagnosis / concern:

Protocol adjustment rationale:

Plan

Plan action:

Continue current protocol

Hold

Increase / titrate

Decrease

Stop

Add new agent

Supplement Protocol

Regimen Name

Supplement protocol

Protocol Phase

Select Phase

Duration

New Supplement

Supplement Name

Form

Select

Strength Value

e.g. 200 mg

Dose Amount

Route

Select

Frequency

Select

Instructions

Adherence

Select

Start Date

yyyy-mm-dd

Stop Date

yyyy-mm-dd

Taper Details

Adverse Effects

+ Add Supplement

Continue / Hold / Start:

Lab orders:

Patient education:

Follow-up interval:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Session Info

Subjective — Interval Update

Symptom Tracking (MSQ)

MSQ

Head

Eyes

Ears

Nose

Mouth/throat

Skin

Heart

Lungs

Digestive tract

Joints/muscles

Weight

Energy/activity

Mind

Emotions

Other

Objective

Vitals

Labs Reviewed

Lab Result

Assessment — Response Since Last Visit

Plan

Supplement Protocol

Supplement Regimen

Supplement Items

Plan and Follow-Up

ND - Follow-Up Session Notes

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