Client Intake Form (Acupuncture)
Personal Information
First Name
Last Name
Date of Birth
Gender
Street Address
City/Suburb
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact
First Name
Last Name
Relationship
Phone Number
Health History
What is the primary reason for seeking acupuncture treatment? (Check all that apply)
Pain Relief (e.g., back pain, joint pain, headaches)
Stress/Anxiety/Depression
Digestive Issues
Sleep Disorders
Women’s Health (e.g., menstrual issues, fertility, menopause)
Allergies/Respiratory Issues
Immune Support
Chronic Fatigue
Other:
Have you been diagnosed with any medical conditions?
If yes, please list.
Are you currently taking any medications or supplements?
If yes, please list.
Do you have any known allergies? (e.g., medications, foods, environmental)
If yes, please specify.
Have you had any surgeries or hospitalizations?
If yes, please list.
Do you have a history of any of the following? (Check all that apply)
High Blood Pressure
Heart Disease
Diabetes
Cancer
Autoimmune Disorders
Neurological Disorders
Other:
Are you pregnant or trying to conceive?
Yes
No
Unsure
Do you have a pacemaker or other implanted medical devices?
If yes, please specify.
Have you received acupuncture before?
If yes, what was your experience?
Lifestyle and Habits
How would you describe your stress levels?
Low
Moderate
High
Very High
How many hours of sleep do you get per night?
Do you exercise regularly?
If yes, what type of exercise and how often?
Do you smoke or use tobacco products?
If yes, how much?
Do you consume alcohol?
If yes, how much?
What is your typical diet like?
Balanced
Vegetarian/Vegan
High in processed foods
Other:
Current Symptoms
Please rate the severity of the following symptoms (1 = mild, 5 = severe)
Pain
Fatigue
Anxiety/Stress
Digestive Issues
Sleep Quality
Are there any specific areas of pain or discomfort?
Please describe location and intensity.
How long have you been experiencing these symptoms?
What makes your symptoms better or worse?
Treatment Preferences and Goals
What are your primary goals for acupuncture treatment? (Check all that apply)
Pain Relief
Stress Reduction
Improved Sleep
Enhanced Energy Levels
Better Digestion
Hormonal Balance
Other:
Are you interested in additional therapies alongside acupuncture? (Check all that apply)
Cupping Therapy
Moxibustion
Electroacupuncture
Herbal Medicine
Dietary Advice
Other:
Do you have any concerns or fears about acupuncture? (e.g., needles, side effects)
Consent and Suitability
Do you have any bleeding disorders or take blood thinners?
Do you have a fear of needles or a history of fainting?
Are you comfortable with the use of needles in your treatment?
Do you understand that acupuncture is generally safe but may have minor side effects such as bruising, soreness, or temporary worsening of symptoms?
Do you consent to acupuncture treatment and any additional therapies discussed?
Client Signature:
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
The Acupuncture Treatments Client Intake Form is a comprehensive tool designed to gather essential information about a client’s health history, lifestyle, symptoms, and treatment preferences. This form ensures that the acupuncturist can provide safe, personalized, and effective care. Below is a detailed breakdown of each section and its significance:
1. Personal Information
This section collects basic demographic details and contact information. It ensures the practitioner can communicate with the client and reach an emergency contact if necessary.
- Date of Birth and Gender: Helps tailor treatments to age- and gender-specific needs (e.g., women’s health issues like menstrual disorders or menopause).
- Emergency Contact: Critical in case of an adverse reaction or medical emergency during treatment.
2. Health History
This section is crucial for identifying contraindications, potential risks, and underlying conditions that may influence treatment.
- Primary Reason for Seeking Treatment: Helps the practitioner focus on the client’s main concerns and prioritize treatment goals.
- Medical Conditions and Medications: Certain conditions (e.g., bleeding disorders, pacemakers) or medications (e.g., blood thinners) may require modifications to treatment.
- Allergies: Ensures the practitioner avoids allergens, especially if using herbal medicine or topical treatments.
- Pregnancy Status: Acupuncture points and techniques may need adjustment for pregnant clients.
- Previous Acupuncture Experience: Provides insight into the client’s comfort level and expectations.
3. Lifestyle and Habits
Lifestyle factors significantly impact health and treatment outcomes. This section helps the practitioner understand the client’s daily habits and stressors.
- Stress Levels: High stress may require a focus on calming techniques and stress-reducing points.
- Sleep and Exercise: Poor sleep or lack of exercise may contribute to symptoms like fatigue or pain.
- Diet: Nutritional habits can influence conditions like digestive issues or inflammation.
- Smoking and Alcohol Use: These habits may affect circulation, energy levels, and overall health.
4. Current Symptoms
This section provides a detailed picture of the client’s current health status and symptom severity.
- Symptom Severity: Helps track progress over time and measure treatment effectiveness.
- Location and Duration of Pain/Discomfort: Guides the practitioner in selecting appropriate acupuncture points.
- Triggers and Relief Factors: Identifies patterns that may inform treatment strategies.
5. Treatment Preferences and Goals
Understanding the client’s goals ensures the treatment plan aligns with their expectations.
- Primary Goals: Helps prioritize treatment focus (e.g., pain relief vs. stress reduction).
- Additional Therapies: Some clients may benefit from complementary therapies like cupping or herbal medicine.
- Concerns or Fears: Addressing fears (e.g., needle phobia) ensures the client feels comfortable and safe.
6. Consent and Suitability
This section ensures the client is fully informed and consents to treatment.
- Bleeding Disorders or Blood Thinners: These conditions may increase the risk of bruising or bleeding from needles.
- Fear of Needles or Fainting: The practitioner can take extra care to make the client comfortable.
- Understanding of Risks: Ensures the client is aware of potential side effects.
- Consent to Treatment: Confirms the client’s agreement to proceed.
7. Practitioner Notes
This section allows the practitioner to document observations, create a treatment plan, and recommend follow-up care.
- Observations: Notes on the client’s demeanor, pulse, tongue (in Traditional Chinese Medicine), or other diagnostic findings.
- Treatment Plan: Outlines the proposed approach, including acupuncture points, techniques, and additional therapies.
- Follow-Up Recommendations: Suggests the frequency of visits and any lifestyle changes to support treatment.
Why This Form is Important
- Safety: Identifies contraindications and ensures treatments are safe for the client.
- Personalization: Tailors treatments to the client’s unique needs, goals, and preferences.
- Effectiveness: Provides a baseline to track progress and adjust treatments as needed.
- Communication: Builds trust by addressing concerns and ensuring the client feels heard.
- Legal Protection: Documents informed consent and protects both the client and practitioner.
How to Use the Form
- Before the First Session: Have the client complete the form in advance or arrive early to fill it out.
- Review Thoroughly: The practitioner should review the form before the session to identify any red flags or areas of focus.
- Discuss During Consultation: Use the form as a guide to ask follow-up questions and clarify details.
- Update Regularly: Revisit the form periodically to track changes in the client’s health or goals.
This intake form is a foundational tool for providing high-quality, client-centered acupuncture care. It ensures the practitioner has all the necessary information to deliver safe, effective, and personalized treatments.
To configure an element, select it on the form.