Tele-Acupuncture Client Intake Form (Holistic Telehealth)
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Address
Street Address
Street Address Line 2
City/Suburb
State/Province
Postal/Zip Code
Country
Phone Number
Email Address
Preferred Method of Communication
Emergency Contact Name
Emergency Contact Phone Number
II. Health History
Primary Health Concerns (please describe):
Medical Diagnoses (if any):
Current Medications/Supplements:
Allergies (food, medications, herbs, etc.):
Surgeries or Hospitalizations (past 5 years):
Family Medical History (e.g., diabetes, heart disease, etc.):
Lifestyle and Wellness
Diet:
Vegetarian
Vegan
Omnivore Diet
Other:
Exercise Routine:
Daily
Weekly
Rarely
None
Other:
Describe your exercise routine:
Sleep Patterns:
Excellent
Good
Fair
Poor
Describe your sleep patterns:
Stress Levels:
Very High
Good
Fair
Poor
Describe your stress levels:
Alcohol/Tobacco/Drug Use:
Regular
Occasional
Former User
None
Describe your alcohol/tobacco/drug use:
Acupuncture and Holistic Wellness Goals
Have you received acupuncture before?
If yes, describe your experience:
What are your primary goals for this consultation? (Check all that apply):
Pain Relief
Stress Reduction
Improved Sleep
Digestive Health
Hormonal Balance
Immune Support
Emotional Well-being
Other:
Are you open to herbal recommendations?
Yes
No
Maybe
Are you interested in learning acupressure techniques for self-care?
Yes
No
Maybe
Tele-Acupuncture Consultation Suitability
Do you have access to a quiet, private space for telehealth consultations?
Do you have a reliable internet connection and a device with a camera?
Are you comfortable with guided self-acupressure or virtual acupuncture consultations?
Yes
No
Unsure
Do you have any concerns about telehealth consultations?
If yes, please describe:
Herbal Recommendations
Are you currently taking any herbal supplements?
If yes, please list:
Do you have any preferences for herbal formulations (e.g., teas, capsules, tinctures)?
If yes, please describe:
Are you pregnant, breastfeeding, or planning to become pregnant?
Yes
No
Not Applicable
Acupressure Techniques
Do you have any areas of pain or tension you would like to address with acupressure?
If yes, please describe:
Are you comfortable applying pressure to specific points on your body?
Yes
No
Unsure
Do you have any physical limitations that might affect your ability to perform acupressure?
If yes, please describe:
Additional Information
Is there anything else you would like us to know about your health or wellness goals?
Consent and Agreement
I understand that tele-acupuncture consultations are not a substitute for in-person medical care and that I should consult my primary healthcare provider for any medical concerns.
I consent to receiving herbal recommendations and acupressure guidance as part of this consultation.
I understand that my personal information will be kept confidential and used solely for the purpose of this consultation.
Client Signature:
Form Template Insight
Form Template Insight
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Below is a detailed breakdown and insights into the Tele-Acupuncture Client Intake Form (Holistic Telehealth). This analysis explains the purpose of each section, the type of information gathered, and how it contributes to a holistic and personalized consultation experience.
1. Client Information
Purpose: To establish basic contact details and ensure proper communication.
Insights:
- Collecting the client’s full name, date of birth, and gender helps personalize the consultation and tailor recommendations based on demographic factors.
- Emergency contact information ensures safety in case of unexpected issues during the consultation.
- Preferred communication method ensures the consultation aligns with the client’s comfort and accessibility.
2. Health History
Purpose: To understand the client’s medical background and identify potential contraindications for acupuncture, herbs, or acupressure.
Insights:
- Primary Health Concerns: Helps focus the consultation on the client’s most pressing issues.
- Medical Diagnoses and Medications: Identifies conditions that may require special consideration (e.g., blood thinners, pregnancy, or chronic illnesses).
- Allergies: Prevents adverse reactions to herbs or materials used in acupressure.
- Surgeries/Hospitalizations: Highlights recent medical events that may impact treatment suitability.
- Family Medical History: Provides context for genetic predispositions (e.g., diabetes, heart disease).
3. Lifestyle and Wellness
Purpose: To assess the client’s daily habits and identify areas for improvement or support.
Insights:
- Diet: Informs herbal recommendations and dietary advice tailored to the client’s eating habits.
- Exercise Routine: Helps determine physical activity levels, which may influence energy flow (Qi) and overall health.
- Sleep Patterns: Poor sleep is often linked to stress, hormonal imbalances, or other health issues that acupuncture and herbs can address.
- Stress Levels: High stress may indicate a need for relaxation techniques, acupressure, or calming herbs.
- Alcohol/Tobacco/Drug Use: Identifies potential detoxification needs or contraindications for certain treatments.
4. Acupuncture and Holistic Wellness Goals
Purpose: To understand the client’s expectations and desired outcomes from the consultation.
Insights:
- Previous Acupuncture Experience: Helps tailor the consultation based on the client’s familiarity with acupuncture.
- Primary Goals: Guides the practitioner in focusing on specific areas (e.g., pain relief, stress reduction, sleep improvement).
- Openness to Herbal Recommendations: Determines if the client is receptive to herbal support as part of their treatment plan.
- Interest in Acupressure: Assesses whether the client is willing to engage in self-care practices.
5. Tele-Acupuncture Consultation Suitability
Purpose: To ensure the client is a good candidate for telehealth services and address any concerns.
Insights:
- Access to a Quiet Space: Ensures the client can focus and engage fully during the consultation.
- Reliable Internet Connection: Confirms the technical requirements for a smooth telehealth experience.
- Comfort with Virtual Consultations: Assesses the client’s readiness for guided self-acupressure or virtual acupuncture.
- Concerns About Telehealth: Provides an opportunity to address any hesitations or limitations.
6. Herbal Recommendations
Purpose: To gather information about the client’s current use of herbs and preferences for herbal formulations.
Insights:
- Current Herbal Supplements: Prevents potential interactions with recommended herbs.
- Preferences for Formulations: Ensures the client receives herbs in a form they are comfortable using (e.g., teas, capsules).
- Pregnancy/Breastfeeding: Identifies special considerations for herbal recommendations, as some herbs are contraindicated during pregnancy.
7. Acupressure Techniques
Purpose: To assess the client’s interest in and suitability for acupressure as a self-care tool.
Insights:
Areas of Pain or Tension: Helps the practitioner target specific acupressure points for relief.
Comfort with Applying Pressure: Determines if the client is physically and mentally prepared to perform acupressure.
Physical Limitations: Identifies any conditions (e.g., arthritis, mobility issues) that may affect the client’s ability to perform acupressure.
8. Additional Information
Purpose: To provide space for the client to share any other relevant details.
Insights:
- This open-ended section allows the client to express concerns, goals, or preferences not covered elsewhere in the form. It ensures a truly personalized consultation.
9. Consent and Agreement
Purpose: To establish clear boundaries and ensure the client understands the scope of telehealth services.
Insights:
- Not a Substitute for Medical Care: Reinforces that tele-acupuncture consultations complement, but do not replace, medical treatment.
- Consent for Herbal Recommendations and Acupressure: Ensures the client is fully informed and agrees to the proposed treatments.
- Confidentiality: Builds trust by assuring the client that their information will be kept private.
Key Benefits of This Intake Form
Comprehensive Assessment: Gathers all necessary information to provide a holistic and personalized consultation.
- Safety: Identifies contraindications and ensures the client’s safety during treatment.
- Client-Centered Approach: Focuses on the client’s goals, preferences, and comfort level.
- Efficiency: Streamlines the consultation process by addressing key questions upfront.
- Legal and Ethical Compliance: Includes consent and confidentiality agreements to protect both the client and practitioner.
How Practitioners Can Use This Form
- Pre-Consultation Review: The practitioner can review the form before the consultation to prepare tailored recommendations.
- Guided Discussion: The form serves as a roadmap for the consultation, ensuring all relevant topics are covered.
- Treatment Planning: The information gathered helps create a customized treatment plan, including acupuncture points, herbal formulas, and acupressure techniques.
- Follow-Up: The form can be updated over time to track progress and adjust treatments as needed.
This intake form is a powerful tool for delivering effective, personalized, and safe tele-acupuncture consultations while fostering a strong practitioner-client relationship.
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