Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Acupuncture Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Primary Reason for Treatment
Pain Location & Intensity
TCM Review of Systems
Sleep & Energy Assessment
Additional details
Digestion & Appetite Patterns
Emotional & Stress Assessment
Prior Acupuncture/TCM History
Western Medical History
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Pregnancy & Bleeding Disorders
Treatment Preferences
Consent & Signature
Date
Acupuncture Intake Form template from formisoft.com. formisoft.com/intake-templates/acupuncture-intake