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Partnering in Your Health: Initial Acupuncture Assessment

1. Patient Demographics

First Name

Last Name

Date of Birth

Gender

Occupation

Phone Number

Email Address

Street Address

City

State/Province

Postal/Zip Code

Emergency Contact Name

Emergency Contact Phone Number

2. Main Complaint

Primary Reason for Visit

When did this begin?

What makes it better? (e.g., heat, cold, pressure, rest)

What makes it worse? (e.g., movement, stress, weather)

Pain Scale: Rate your current level of pain from 1 (minimal) to 10 (severe).

Pain Character

Sharp/Stabbing

Dull/Aching

Burning

Numb/Tingling

Fixed

Moving

3. Medical History & Lifestyle

Current Medications & Supplements

Known Allergies (Latex, Metals, Medications)

Past Surgeries/Traumas

Type of Surgery/Trauma

When?

A
B
1
 
 
2
 
 
3
 
 
4
 
 
5
 
 
 

Lifestyle Habits

 

Tobacco/Nicotine

Alcohol

Average hours of sleep per night

Current Stress Level: Rate your stress over the past week from 1 (minimal) to 10 (severe).

4. Systems Review (TCM Focused)

Please check any symptoms you experience regularly.

 

Thermoregulation & Energy

Chills/Cold intolerance

Fever/Heat intolerance

Night sweats

Afternoon fatigue

Heavy sensation in the body

Digestion & Elimination

Bloating/Gas

Heartburn/Reflux

Loose stools/Diarrhea

Constipation

Strong thirst

Sleep & Emotions

Difficulty falling asleep

Waking up frequently

Vivid dreaming/Nightmares

Anxiety/Panic

Frequent irritability or anger

Respiratory & Immune

Shortness of breath

Chronic cough

Frequent colds/flu

Sinus congestion

5. Women’s Health

Are you currently pregnant?

Yes

No

Trying

Cycle Length (days)

Duration of flow (days)

Pain/Cramping

Before

During

After flow

Blood Quality

Bright red

Dark/Purple

Clotted

6. Practitioner Diagnostic Notes (Internal Use)

This section is for the acupuncturist to fill out during the physical examination.

 

Pulse Diagnosis

Position

Left

Right

A
B
C
1
Cun (Inch)
 
 
2
Guan (Gate)
 
 
3
Chi (Foot)
 
 

General Quality

 

Tongue Diagnosis

 

Body Color

Pale

Pink

Red

Purple

Dusky

Coating

Thin

Thick

White

Yellow

Peeled/Geographic

Shape

Swollen

Thin

Teeth marks (scalloped)

Tremivering

 

Physical Exam/Palpation

 

Ashi Points/Trigger Points

Abdominal Palpation (Hara)

7. Assessment & Treatment Plan

TCM Pattern Diagnosis

Treatment Principle

Point Selection

Adjunct Therapies

Cupping

Moxa

Gua Sha

Herbs

Recommended Frequency in Times per Week

How many weeks is the total duration of the treatment?

Form Template Insights

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Detailed Insights on the Acupuncture Initial Evaluation Form Template

1. The Narrative vs. The Specifics (Main Complaint)

The "Main Complaint" section is designed to capture the history of the present illness.

  • The "Why Now" Factor: Knowing why a patient is seeking help today versus six months ago identifies the "tipping point" in their health.
  • Ameliorating/Aggravating Factors: In acupuncture, if heat makes a pain better, it indicates a "Cold" or "Deficiency" pattern. If pressure makes it worse, it indicates an "Excess" or "Stagnation" pattern. This dictates whether the practitioner should add energy to the body or move blocked energy.

2. The "Ten Questions" Framework (Systems Review)

Traditional Chinese Medicine often relies on a systematic inquiry known as the "Ten Questions." This section is designed to detect patterns that a patient might think are unrelated to their main pain.

  • Sleep and Digestion: These are the "Engine" indicators. If a patient has back pain but also has poor digestion, the practitioner knows the body isn't producing enough nutrients to repair the muscles.
  • Thermoregulation: Identifying "Internal Heat" versus "Internal Cold" tells the practitioner whether to use Moxibustion (warming) or Guasha (clearing heat).

3. The Objective Physical Markers

This is where the form shifts from the patient's perspective to the practitioner's observation. These markers are essential for tracking progress over time.

  • Tongue Diagnosis: The tongue is the only internal organ visible to the naked eye. The color of the "body" shows the state of the blood, and the "coating" shows the state of the digestion.
  • Pulse Diagnosis: This provides a real-time read of the body’s "energetic weather." A "Wiry" pulse often points to stress or liver-gallbladder tension, while a "Slippery" pulse can indicate inflammation or dampness.

4. Safety-Critical Information

Even without considering regulatory frameworks, certain medical data is vital for a safe physical intervention:

  • Blood Thinners and Clotting: Acupuncture involves micro-trauma. Knowing if a patient bruises easily or is on medication that affects clotting determines the gauge (thickness) of the needle used and the duration of the treatment.
  • Faintness/Hypoglycemia: Patients who have not eaten before a session are prone to "needle shock" (vasovagal syncope). A mandatory question about the last time they ate prevents fainting during the session.

5. Menstrual and Reproductive Health

In TCM, the menstrual cycle is viewed as a "monthly report card" for the body's internal balance.

  • The Flow Quality: Clotting or dark blood signifies "Blood Stasis," which is often the root cause of physical pain elsewhere in the body, such as chronic headaches or shoulder tension.
  • Fertility Support: If a patient is trying to conceive, the practitioner must avoid certain points that have a downward-draining effect on the pelvic cavity.

6. Treatment Planning and Frequency

The final section of the form turns the data into action.

  • The Pattern Diagnosis: Instead of just saying "lower back pain," the form allows for a TCM diagnosis like "Kidney Qi Deficiency."
  • Dose-Response Curve: Like any therapy, acupuncture is cumulative. This section allows the practitioner to set expectations—explaining that chronic conditions may require 6–10 sessions to see lasting change.


Mandatory Questions Recommendation

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Mandatory Questions & Core Rationale:

1. Known Allergies (Latex, Metals, Adhesives)

Why it’s mandatory: This is the most critical safety question. Acupuncture involves physical tools.

  • Needle Composition: Many needles contain nickel. An undisclosed metal allergy can cause skin reactions at the insertion site.
  • Adjunct Tools: If you use silicone cups (latex) or adhesive surgical tape to secure ear seeds, you must know if the patient’s skin will react to these materials.

2. Current Medications & Supplements

Why it’s mandatory: Modern medications significantly alter the body’s "internal landscape," which can change how a practitioner interprets TCM signs.

  • Blood Thinners: Patients on anticoagulants may bruise or bleed more easily, requiring a specialized needling technique or the avoidance of certain points.
  • Beta-Blockers: These can mask a patient’s true pulse quality, making it appear slower or more regular than the underlying TCM pattern would suggest.

3. Pregnancy Status

Why it’s mandatory: In acupuncture, there are "forbidden points"—specific areas on the body (such as the lower abdomen or certain points on the hand and ankle) that are known to strongly descend energy.

  • Safety: Using these points during pregnancy could cause uterine contractions or complications. Every practitioner must confirm this status to ensure the treatment supports the pregnancy rather than disrupting it.

4. Character of Pain (Fixed vs. Moving)

Why it’s mandatory: In TCM, the "flavor" of the pain is the primary diagnostic tool for identifying the root cause.

  • Fixed/Stabbing Pain: Suggests "Blood Stasis," requiring a treatment focus on circulation.
  • Moving/Aching Pain: Suggests "Qi Stagnation" or "Wind," requiring a focus on the nervous system and smoothing the energy flow.
  • Without this distinction, the practitioner is just treating a symptom rather than the source.

5. Thermoregulation (Heat vs. Cold)

Why it’s mandatory: You cannot create a TCM formula or point prescription without knowing the "temperature" of the patient’s condition.

  • Cold Patterns: Require the use of Moxibustion (heat therapy) to build energy.
  • Heat Patterns: Require "clearing" techniques. Applying heat to a patient who already has an internal heat pattern can exacerbate their symptoms, such as increasing inflammation or causing insomnia.

6. Tongue and Pulse Examination

Why it’s mandatory: These are the "objective labs" of acupuncture.

  • Validation: Patients may forget to mention a symptom, but the tongue and pulse provide a physical map of the internal organs. They confirm whether the patient's self-reported symptoms align with their physiological state, ensuring the treatment plan is accurate and effective.


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