Functional Health New Patient Intake Brief.

Medication, OTC, and supplement inventory

This section is not an interaction checker. It is a structured inventory for clinician review.

1. Patient/admin summary

The patient is attending for a first functional health consultation focused on persistent fatigue, sleep disruption, bloating after meals, and afternoon concentration dips. Their stated priorities are to understand possible contributors, review their current supplement stack, and arrive with clearer questions for the appointment.

Clarify which concern is most important to address first, and whether the patient's priority differs from the apparent clinical priority.

2. Chief concerns

Main concerns are fatigue, unrefreshing sleep, bloating after meals, and difficulty sustaining concentration in the afternoon. Symptoms have been present for more than six months and are affecting work performance and exercise consistency.

Ask what changed around onset, what has already been tried, and what would make the consultation feel successful to the patient.

3. Timeline and context

Symptoms appear to have worsened after a period of high work stress and reduced sleep. The patient reports adding several supplements during this period but is unsure which, if any, helped. No recent lab values were entered.

Reconstruct the order of symptom onset, supplement additions, medication changes, and any investigations already completed.

4. Safety and red-flag prompts

Two answers in this submission warrant review before discussing additions or changes. The patient reports unintentional weight loss of approximately 4 kg over the past three months without a deliberate change in eating or activity, and reports starting a daily over-the-counter NSAID for joint pain alongside a prescription medication and several supplements.

Clarify weight-loss context against the clinic's red-flag pathway. Confirm the prescription medication name, indication, and any anticoagulant or interaction risk before discussing supplement additions.

5. Lifestyle signals

Intake answers suggest fatigue may be occurring in the context of short sleep, late caffeine, irregular meal timing, and high perceived stress. These are discussion areas rather than conclusions.

Clarify which lifestyle factors are realistic targets for this patient and which may be consequences of the underlying issue.

6. Food pattern and nutrient context

The patient reports inconsistent breakfast, low weekday protein intake, and frequent bloating after evening meals. They do not report a vegan or vegetarian diet. No recent ferritin, B12, vitamin D, thyroid, or glucose markers were entered.

Explore whether food pattern is a driver, response, or unrelated context. Consider whether any lab discussion is appropriate based on clinical judgement and clinic scope.

7. Sleep, energy, stress, and cognition

The patient reports unrefreshing sleep and afternoon concentration dips. There is not enough information in the intake to determine whether sleep timing, sleep quality, circadian disruption, stress, or another factor is most relevant.

Clarify snoring, witnessed apnoea, morning headaches, daytime sleepiness, shift work, caffeine timing, and sleep schedule if clinically appropriate.

8. Labs and investigations to discuss

No recent lab values were entered. The patient reports fatigue lasting more than six months and currently takes vitamin D without a recorded recent level.

Depending on clinical judgement and clinic scope, clarify whether recent blood count, ferritin, B12, vitamin D, thyroid, glucose/HbA1c, liver/kidney markers, or inflammatory markers are already available.

9. Missing information

Missing or unclear: dose of vitamin D, dose of magnesium, exact prescription medication name, date of last blood tests, whether fatigue started before or after sleep disruption, and whether digestive symptoms include alarm features not captured in the intake.

Use this section as a quick checklist before reading the full answer appendix.

10. Suggested first-consult agenda

1. Address the flagged weight-loss context first.
2. Confirm prescription medication, daily NSAID use, and supplement details.
3. Clarify symptom timeline against onset of high stress.
4. Explore sleep quality, caffeine timing, and stress load.
5. Review digestive pattern and food triggers.
6. Decide whether recent labs are sufficient for the clinic’s assessment.
7. Agree what the patient wants to prioritise first.

This agenda is generated from intake answers and should be edited or ignored according to clinician judgement.

11. Full answer appendix

The appendix preserves the patient’s submitted answers, separated from system-generated summaries.

• Admin and appointment context.
• Patient goals.
• Symptoms and timeline.
• Medical history.
• Medications, OTC products, and supplements.
• Allergies and adverse reactions.
• Sleep and energy.
• Food pattern and digestion.
• Stress, movement, and work pattern.
• Labs and investigations.
• Family history.
• Patient questions for clinician.

Delivery note

Generated on the patient’s device and sent directly to the clinic by the patient. Almavivo did not receive, store, or transmit this submitted intake package.