Acupuncture Intake Form
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Acupuncture Intake Form
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The Acupuncture Intake Form is specifically designed for acupuncture and Traditional Chinese Medicine (TCM) practices, capturing both the Western medical history and the TCM-specific assessment data that licensed acupuncturists need for individualized treatment planning. This template collects patient demographics alongside a detailed chief complaint assessment, pain mapping with intensity scales, and a comprehensive review of systems organized by TCM organ systems covering sleep quality, digestion, appetite, thirst patterns, temperature sensitivity, perspiration, energy levels, emotional state, menstrual history (when applicable), and urinary and bowel patterns.
Built for acupuncture practices, TCM clinics, integrative medicine centers, and holistic wellness practices, this form includes sections for TCM constitution assessment (yin/yang balance, qi and blood patterns, five element tendencies), prior acupuncture and TCM treatment history (cupping, moxibustion, herbal formulas, gua sha), Western medical history and current medications, surgical history, allergies, pregnancy status, bleeding disorders or anticoagulant use (critical for needling safety), and lifestyle factors including diet, exercise, stress levels, and emotional well-being. The treatment preference section captures needle sensitivity, areas to avoid, and comfort considerations.
All fields are HIPAA-compliant and structured for the acupuncture intake workflow. The dual Western-TCM format ensures that acupuncturists have both the safety information needed for safe needling (contraindications, bleeding risk, pregnancy) and the TCM diagnostic data needed for pattern differentiation and point selection. Pre-visit completion allows practitioners to begin formulating their treatment approach before the patient arrives.
What's included
- TCM review of systems and constitution assessment
- Pain mapping with intensity and pattern documentation
- Sleep, digestion, and energy level evaluation
- Needling safety screening (pregnancy, bleeding risk)
- Prior acupuncture and TCM treatment history
- Western medical history and medication reconciliation
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Licensed acupuncture and TCM practices
- Integrative medicine and holistic health clinics
- Pain management with complementary acupuncture
- Wellness and preventive acupuncture programs
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Acupuncture Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Acupuncture Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Acupuncture Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Acupuncture Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Acupuncture Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Acupuncture Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Acupuncture Intake Form for your practice. Set up in minutes.
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