Client Intake Form (Acupuncture)

Person receiving acupuncture treatment, representing holistic health

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)

Have you been diagnosed with any medical conditions?

Are you currently taking any medications or supplements?

Do you have any known allergies? (e.g., medications, foods, environmental)

Have you had any surgeries or hospitalizations?

Do you have a history of any of the following? (Check all that apply)

Are you pregnant or trying to conceive?

Do you have a pacemaker or other implanted medical devices?

Have you received acupuncture before?

Lifestyle and Habits

How would you describe your stress levels?

How many hours of sleep do you get per night?

Do you exercise regularly?

Do you smoke or use tobacco products?

Do you consume alcohol?

What is your typical diet like?

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?


Treatment Preferences and Goals

What are your primary goals for acupuncture treatment? (Check all that apply)

Are you interested in additional therapies alongside acupuncture? (Check all that apply)

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

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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

  1. Safety: Identifies contraindications and ensures treatments are safe for the client.
  2. Personalization: Tailors treatments to the client’s unique needs, goals, and preferences.
  3. Effectiveness: Provides a baseline to track progress and adjust treatments as needed.
  4. Communication: Builds trust by addressing concerns and ensuring the client feels heard.
  5. Legal Protection: Documents informed consent and protects both the client and practitioner.

How to Use the Form

  1. Before the First Session: Have the client complete the form in advance or arrive early to fill it out.
  2. Review Thoroughly: The practitioner should review the form before the session to identify any red flags or areas of focus.
  3. Discuss During Consultation: Use the form as a guide to ask follow-up questions and clarify details.
  4. 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.

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