Free Template
SOAP Note Template for Naturopathy
Naturopathic doctors require comprehensive documentation that integrates conventional lab work with naturopathic treatment approaches including botanical medicine, clinical nutrition, and lifestyle counseling. This template accommodates the whole-person assessment model used in naturopathic practice.
Blank Naturopathy SOAP Note Template
Copy this template and fill in the bracketed sections with your session details.
SUBJECTIVE: Patient presents with [chief complaint]. [History of present illness]. [Review of systems: sleep, digestion, energy, mood, skin, hormonal]. [Diet and lifestyle overview]. [Current medications and supplements]. [Relevant medical and family history]. OBJECTIVE: Vitals: [BP, HR, temp, weight if relevant]. Physical exam: [relevant findings]. Lab results: [if available — blood work, hormone panels, food sensitivity tests]. Functional assessments: [adrenal questionnaire, digestive assessment, toxicity screening]. ASSESSMENT: [Clinical impression/naturopathic diagnosis]. [Root cause analysis — e.g., gut dysbiosis, HPA axis dysfunction, nutritional deficiency]. [Prioritization of treatment goals]. PLAN: Dietary recommendations: [specific changes]. Supplements: [name, dose, frequency, duration]. Botanical medicine: [herbs, form, dosage]. Lifestyle: [exercise, stress management, sleep hygiene]. Labs ordered: [if applicable]. Follow-up: [timeline and goals for next visit].
Filled Example — Naturopathy
Here's what a completed SOAP note looks like for a naturopathy session.
SUBJECTIVE: Patient presents with chronic fatigue and brain fog of 8 months duration. Reports energy is 3/10 in the morning, improving slightly to 5/10 by afternoon. Associated symptoms include difficulty concentrating, sugar cravings (especially 3-4 PM), disrupted sleep (waking at 2-3 AM and unable to return to sleep), and increased anxiety over the past 6 months. Digestion: daily bloating after meals, alternating constipation/loose stools. Skin: adult acne on jawline, worsening premenstrually. Diet: high in processed foods, coffee 3 cups/day, minimal vegetable intake. Exercise: none currently (too fatigued). Currently taking: oral contraceptive pill (4 years), multivitamin (inconsistent). Family history: mother with Hashimoto's thyroiditis, father with type 2 diabetes. OBJECTIVE: Vitals: BP 108/68, HR 72, weight 152 lbs (up 12 lbs in 8 months). Physical exam: mild bilateral thyroid enlargement on palpation, tongue has thick white coating with scalloped edges, dark circles under eyes, dry skin on elbows and shins. Lab results reviewed (drawn 1 week ago): TSH 4.2 mIU/L (ref 0.4-4.0), free T4 0.9 ng/dL (ref 0.8-1.8), free T3 2.1 pg/mL (ref 2.3-4.2), TPO antibodies 89 IU/mL (ref <35), fasting glucose 95, HbA1c 5.4%, vitamin D 18 ng/mL (ref 30-80), ferritin 15 ng/mL (ref 20-200), B12 320 pg/mL (ref 200-900). Cortisol saliva (4-point): elevated morning, low midday and afternoon, elevated evening — pattern consistent with HPA axis dysregulation. ASSESSMENT: 1. Subclinical hypothyroidism with elevated TPO antibodies — early Hashimoto's thyroiditis, consistent with family history. Low free T3 suggests impaired T4-to-T3 conversion. 2. HPA axis dysregulation with disrupted cortisol rhythm contributing to fatigue, sleep disturbance, and afternoon sugar cravings. 3. Nutritional deficiencies: vitamin D insufficiency, low ferritin (borderline iron deficiency), suboptimal B12. 4. Suspected gut dysbiosis based on digestive symptoms, tongue coating, and association with autoimmune thyroid. Primary root causes: gut-immune connection driving thyroid autoimmunity, HPA axis dysfunction, nutritional depletion. PLAN: Dietary recommendations: Implement anti-inflammatory whole foods diet. Eliminate gluten for 6-week trial (gluten-thyroid connection). Reduce coffee to 1 cup before noon. Increase vegetables to 6+ servings daily, emphasizing cruciferous vegetables (cooked) and leafy greens. Add fermented foods (sauerkraut, kimchi) daily for gut support. Supplements: Vitamin D3 5,000 IU daily with K2 100 mcg (retest in 8 weeks). Iron bisglycinate 25 mg every other day with vitamin C (away from thyroid-affecting supplements). Methylcobalamin B12 1,000 mcg sublingual daily. Selenium 200 mcg daily (thyroid and conversion support). Magnesium glycinate 400 mg at bedtime (sleep, HPA support). Botanical medicine: Ashwagandha (Withania somnifera) 600 mg standardized extract daily (adaptogen for HPA and thyroid). Rhodiola rosea 200 mg morning (energy and cognitive support). Chamomile tea before bed (sleep support). Lifestyle: Begin gentle movement — 20-minute daily walks. Sleep hygiene: no screens after 9 PM, bedroom temp 65-68°F. 10-minute guided meditation daily (HPA axis reset). Labs ordered: Comprehensive stool analysis (GI-MAP) to assess microbiome. Recheck thyroid panel, vitamin D, and ferritin in 8 weeks. Follow-up: 4 weeks to assess energy, sleep, and digestive changes. Discuss stool analysis results.
Documentation Tips for Naturopathy
- Document the full picture: diet, lifestyle, stress, sleep — not just the chief complaint
- Include lab values with reference ranges for context
- Provide specific supplement names, doses, and rationale
- Note root cause analysis — this is what distinguishes naturopathic documentation
- Include dietary recommendations with enough detail for the patient to follow
- Track progress with subjective scales (energy X/10) for longitudinal comparison
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