Acupuncture Treatments Client Intake Form
I. Client Information
First Name
Last Name
Date of Birth
Gender
Occupation
Contact Information
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Postal/Zip Code
Emergency Contact
Full Name
Phone Number
Referred By (if applicable)
II. Medical History
Primary Complaint/Reason for Seeking Treatment: (Describe your current health concerns and goals for acupuncture treatment.)
Onset of Symptoms: (When did you first notice the symptoms?)
Description of Symptoms: (Please describe the nature, location, intensity, and duration of your symptoms.)
Pain Scale (if applicable): (On a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, rate your current pain level.)
Previous Treatments: (Have you received acupuncture or other related therapies before?
Current Medications (Prescription, Over-the-Counter, Supplements): (Please list all medications and supplements you are currently taking, including dosage.)
Allergies: (Please list any allergies, including medications, foods, and environmental factors.)
Past Medical History: (Please list any past illnesses, surgeries, or injuries.)
Current Medical Conditions: (Please list any current medical conditions, including chronic illnesses.)
Family Medical History: (Are there any significant medical conditions that run in your family?)
III. Lifestyle and Habits
Diet
Please describe your typical diet.
Exercise
How often do you exercise?
What type of exercise do you do?
Smoking
Do you smoke?
Alcohol Consumption
How often do you consume alcohol?
How much?
Caffeine Consumption
How much caffeine do you consume daily?
Stress Levels
How would you rate your stress levels on a scale of 1-10? (With 0 being Low Stress and 10 being High Stress)
IV. Acupuncture Treatment Options and Suitability
General Acupuncture
(For pain relief, stress reduction, and overall well-being)
Are you comfortable with the use of fine needles?
Do you have any bleeding disorders?
Electroacupuncture
(Uses electrical stimulation in conjunction with acupuncture needles)
Do you have a pacemaker or other implanted electronic device?
Do you have a history of seizures?
Auricular Acupuncture (Ear Acupuncture)
(Focuses on points in the ear)
Do you have any ear infections or skin conditions in the ear?
Are you prone to keloid scarring?
Cupping Therapy
(Uses suction cups to create a vacuum on the skin)
Do you have any skin conditions, such as eczema or psoriasis?
Do you have any bleeding disorders?
Are you taking any blood thinners?
Moxibustion
(Uses heat from burning moxa herb)
Are you sensitive to smoke or heat?
Do you have any skin conditions that could be irritated by heat?
Gua Sha
(Uses a smooth tool to scrape the skin)
Do you have any skin conditions or are you taking blood thinners?
Are you prone to bruising?
Tui Na
(Chinese Medical Massage)
Do you have any bone fractures, dislocations, or severe osteoporosis?
Do you have any acute injuries or inflammation?
Cosmetic Acupuncture
(Acupuncture for facial rejuvenation)
Do you have any skin disorders?
Have you had any recent facial surgeries or procedures?
Fertility Acupuncture
Are you currently undergoing any fertility treatments?
Are you taking any fertility medications?
Sports Acupuncture
Have you had any recent sports related injuries?
What sports do you participate in?
V. Consent
I understand that acupuncture involves the insertion of fine needles into specific points on the body.
I understand that other therapies, such as cupping, moxibustion, gua sha, and tui na, may be used as part of my treatment.
I have accurately provided all relevant medical and personal information to the best of my knowledge.
I consent to receive acupuncture and related therapies as deemed appropriate by the practitioner.
I understand that results are not guaranteed.
I have had the oppertunity to ask any questions that I may have.
Client Signature
Form Template Insight
Form Template Insight
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Important Considerations:
- This form is for informational purposes and should not be considered medical advice.
- Always consult with a licensed and qualified acupuncturist before starting any treatment.
- Tailor the form to your specific practice and the treatments you offer.
- Keep all patient information confidential, in accordance with all relevant privacy laws.
- Always ask if the patient has any questions before beginning treatment.
By using this comprehensive intake form, you can gather essential information, assess treatment suitability, and provide personalized care to your acupuncture clients.
Let's break down the client intake form section by section, providing a detailed insight into its purpose and importance:
1. Client Information:
Purpose: This section gathers basic demographic and contact information.
Importance:
- Accurate identification: Ensures correct patient records.
- Communication: Enables easy contact for appointments, follow-ups, or emergencies.
- Emergency preparedness: Provides vital information in case of an adverse event.
2. Medical History:
Purpose: This is the core of the intake form, designed to understand the client's current health status, past medical events, and potential contraindications.
Importance:
- Accurate diagnosis: Helps the acupuncturist understand the root cause of the client's complaint.
- Treatment planning: Guides the selection of appropriate acupuncture points and techniques.
- Safety: Identifies potential risks and contraindications, such as bleeding disorders, pregnancy, or medication interactions.
- Detailed Breakdown:
- Primary Complaint/Onset/Description: These questions paint a picture of the immediate reason for the appointment.
- Pain Scale: Quantifies pain levels for tracking progress.
- Previous Treatments: reveals if the patient has had positive or negative experiances with similar treatments.
- Current Medications/Allergies: Crucial for preventing adverse reactions and drug interactions.
- Past/Current Medical History: Provides a comprehensive overview of the client's health.
- Family Medical History: Can reveal genetic predispositions.
- Women's Health: Specific questions are vital for safe and effective treatment of female clients. Hormonal changes impact treatment.
- Systemic Reviews (Digestive, Sleep, Emotional, etc.): These sections explore the interconnectedness of bodily systems, a core concept in traditional Chinese medicine.
- Other Relevant Information: Allows the patient to add anything that was missed.
3. Lifestyle and Habits:
Purpose: This section explores the client's lifestyle factors that can influence their health and treatment outcomes.
Importance:
- Holistic approach: Recognizes the impact of lifestyle on overall well-being.
- Treatment customization: Helps tailor treatment plans to address lifestyle factors.
- Patient education: Provides opportunities to educate clients on healthy habits.
- Detailed Breakdown:
- Diet, Exercise, Smoking, Alcohol, Caffeine: These factors directly affect the body's energy and balance.
- Stress Levels: Stress is a major contributor to many health issues.
4. Acupuncture Treatment Options and Suitability:
Purpose: This section informs the client about the various treatment options available and assesses their suitability for each.
Importance:
- Informed consent: Ensures the client understands the treatments they are receiving.
- Safety: Identifies contraindications for specific techniques.
- Personalization: Allows the acupuncturist to select the most appropriate treatments for the client's individual needs.
- Detailed Breakdown:
- Each treatment option (e.g., electroacupuncture, cupping, moxibustion) is accompanied by specific questions to assess suitability. For instance, electroacupuncture is contraindicated for clients with pacemakers.
- Specific questions regarding cosmetic acupuncture, fertility acupuncture, and sports acupuncture, allow the practitioner to gain needed information for those specialized treatments.
5. Consent:
Purpose: This section documents the client's informed consent to receive acupuncture and related therapies.
Importance:
Legal protection: Protects the acupuncturist from liability.
Ethical practice: Ensures the client's autonomy and right to make informed decisions.
Key Elements:
- Understanding of the procedures: Confirms that the client understands what acupuncture involves.
- Disclosure of information: Acknowledges that the client has provided accurate information.
- Voluntary consent: Indicates that the client has freely chosen to receive treatment.
- Acknowledgement that results are not guaranteed.
- Acknowledgement that the patient has had the oppertunity to ask questions.
Overall Importance of the Form:
- Comprehensive Assessment: Provides a holistic view of the client's health.
- Safety and Efficacy: Ensures safe and effective treatment by identifying contraindications and tailoring treatment plans.
- Documentation: Creates a detailed record of the client's health history and treatment.
- Client-Centered Care: Promotes informed consent and empowers clients to participate in their own health care.
- Professionalism: Demonstrates a commitment to thoroughness and high-quality care.
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