Holistic Wellness Telehealth -
Tele-Acupuncture Consultations
Client Intake Form

Virtual acupuncture wellness consultation.

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



Phone Number

Email Address


Preferred Method of Communication

Emergency Contact Name

Emergency Contact Phone Number

II. Health History

Primary Reason for Seeking Consultation: (Please describe your main health concerns or goals)

Onset of Current Symptoms: (When did your current symptoms begin?)

Detailed Description of Symptoms: (Please provide a thorough description, including location, intensity, and any triggers)

Past Medical History: (Please list any previous illnesses, surgeries, or injuries)

Current Medications: (Please list all medications, including dosage and frequency)

Allergies: (Please list any allergies, including reactions)

Current Supplements: (Please list all supplements, vitamins, and herbal remedies)

Family Medical History: (Any significant hereditary conditions?)


Lifestyle Habits:


Diet: (Describe your typical daily diet)

Exercise: (Describe your exercise routine)

Sleep: (Describe your sleep patterns)

Stress Levels: (Rate your stress levels on a scale of 1-10, 1 being low, 10 being high)

Smoking/Alcohol/Drug Use: (Please specify)

For Women:

Menstrual Cycle: (Describe regularity, duration, any associated symptoms)

Pregnancy/Breastfeeding: (Are you currently pregnant or breastfeeding?)

III. Telehealth Suitability and Technical Requirements

Do you have access to a reliable internet connection?

Do you have a device with a camera and microphone (smartphone, tablet, or computer)?

Do you have a private and quiet space for the consultation?

Are you comfortable with using video conferencing software?

Do you understand that tele-acupuncture consultations involve guidance on acupressure and lifestyle recommendations, and do not involve physical needle insertion?

Do you understand that herbal recommendations are based on your health history and symptoms, and you should consult with your primary care physician before starting any new herbal remedies?

Do you understand that tele-health is not a replacement for emergency medical care?

Are you aware that some conditions are not suitable for Telehealth, and that you might be refered to in person care?

Do you have any conditions that affect blood clotting, or have a pacemaker?

IV. Consultation Options

Please indicate which type of consultation you are interested in:

V. Herbal Recommendations

Do you have any known sensitivities or allergies to herbs?

Do you understand that herbal recommendations are not a substitute for conventional medical treatment?

Are you currently taking any other herbal supplements?

Are you willing to purchase herbal remedies as recommended?

VI. Acupressure Guidance

Have you had any previous experience with acupressure?

Do you have any physical limitations that may affect your ability to perform acupressure?

Do you understand that acupressure should be performed with gentle pressure and discontinued if any discomfort occurs?

Are you willing to participate in guided acupressure sessions via video conferencing?

VII. Consent and Agreement

I understand that the information provided in this form will be kept confidential and used for the purpose of my telehealth consultation.

I understand that telehealth consultations have limitations and may not be suitable for all medical conditions.

I agree to follow the recommendations provided by the practitioner and to inform them of any changes in my health status.

I have read and understand the terms and conditions of the telehealth service.

I consent to receive telehealth consultations and herbal recommendations.

Signature:

Form Template Insight

Please remove this form template insight section before publishing.


Important Considerations:


  • HIPAA Compliance: Ensure your telehealth platform and intake form comply with HIPAA regulations (or equivalent privacy laws in your region) to protect patient confidentiality.
  • Disclaimer: Include a clear disclaimer stating that telehealth consultations are not a substitute for in-person medical care and that emergency situations should be addressed by calling emergency services.
  • Technical Support: Provide clear instructions on how to access the telehealth platform and offer technical support if needed.
  • Payment and Scheduling: Outline your payment policies and scheduling procedures.
  • Follow-Up: Establish a clear follow-up plan to monitor patient progress and address any concerns.

This comprehensive intake form should help you gather the necessary information to provide effective and safe telehealth consultations. Remember to tailor the form to your specific practice and the needs of your clients.



Let's dissect this client intake form and delve into the detailed insights behind each section:


Section 1: Personal Information


Purpose:

  • Establishes basic client identification and contact details.
  • Facilitates communication and scheduling.
  • Provides emergency contact information for safety.

Insights:

  • "Preferred Method of Communication" allows for personalized interaction.
  • Accurate address information is vital for potential future mailings or legal purposes.

Section 2: Health History


Purpose:

  • Gathers comprehensive information about the client's current and past health.
  • Identifies potential contraindications for tele-acupuncture, herbal remedies, and acupressure.
  • Helps the practitioner understand the root cause of the client's health concerns.

Insights:

  • "Primary Reason for Seeking Consultation" is crucial for setting treatment goals.
  • Detailed symptom description helps the practitioner formulate a personalized treatment plan.
  • "Current Medications," "Allergies," and "Current Supplements" are critical for avoiding potential interactions.
  • "Family Medical History" can reveal hereditary predispositions.
  • Lifestyle habits are vital, as they greatly impact health.
  • The female specific questions are required to ensure no harm will come to mother or child.

Important Note:

  • This section should be approached with sensitivity and confidentiality.
  • Clients should feel comfortable providing honest and complete information.

Section 3: Telehealth Suitability and Technical Requirements


Purpose:

  • Ensures the client has the necessary technical capabilities for a successful telehealth consultation.
  • Assesses the client's understanding of the limitations and expectations of tele-acupuncture.
  • Ensures that the client understands that Tele-health is not for every situation.

Insights:

  • "Reliable internet connection" and "device with camera and microphone" are essential for video conferencing.
  • "Private and quiet space" ensures confidentiality and minimizes distractions.
  • The questions about understanding tele-acupuncture and herbal recommendations protect both the client and the practitioner.
  • The questions regarding blood clotting and pacemakers are vital for safety, as some acupressure points can affect these conditions.

Legal Considerations:

  • This section helps mitigate legal risks by documenting the client's informed consent.

Section 4: Consultation Options


Purpose:

  • Clearly outlines the different types of consultations offered.
  • Allows the client to choose the services that best meet their needs.
  • Sets expectations for the client.

Insights:

  • Offering a variety of consultation options caters to diverse client needs.
  • Detailed descriptions of each consultation help clients make informed decisions.
  • Wellness coaching adds a valuable extra service.

Section 5: Herbal Recommendations (If Applicable)


Purpose:

  • Gathers information about the client's experience with and potential sensitivities to herbs.
  • Ensures the client understands the limitations and responsibilities associated with herbal remedies.

Insights:

  • "Known sensitivities or allergies to herbs" is crucial for avoiding adverse reactions.
  • Reinforcing that herbal recommendations are not a substitute for medical treatment is essential.
  • Asking about current herbal supplements helps prevent interactions.

Ethical Considerations:

  • Practitioners should only recommend herbs that they are qualified to prescribe.

Section 6: Acupressure Guidance


Purpose:

  • Assesses the client's experience with and physical ability to perform acupressure.
  • Ensures the client understands the importance of performing acupressure safely.

Insights:

  • "Previous experience with acupressure" helps the practitioner tailor their guidance.
  • "Physical limitations" helps the practitioner modify techniques as needed.
  • Emphasizing gentle pressure and discontinuing if discomfort occurs promotes safety.

Practical Considerations:

  • Clear demonstrations and personalized guidance are essential for effective tele-acupressure.

Section 7: Consent and Agreement


Purpose:

  • Documents the client's informed consent to receive telehealth consultations and herbal recommendations.
  • Protects the practitioner from legal liability.

Insights:

  • Clear and concise language is essential for ensuring the client understands the terms and conditions.
  • A signed consent form provides legal documentation of the agreement.

Legal Compliance:

  • Ensure the consent form complies with all applicable laws and regulations.

Overall Insights:


  • This intake form is designed to be comprehensive and thorough, covering all essential aspects of a telehealth consultation.
  • It prioritizes client safety, confidentiality, and informed consent.
  • It allows for personalized treatment planning and effective communication.
  • It protects the practioner.
  • It is vital to review this form regularly, and update it as laws, or best practices change.
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