Acupuncture Intake Form

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.