Acupuncture Intake Form Template
Collects contact details, health concerns, wellness ratings, medication information, feelings about needles, and consent for acupuncture. Used by acupuncturists before an appointment.
When to use it
- Before a new patient’s first acupuncture appointment
- When updating a returning patient’s intake details
- Before discussing medications, supplements, or needle concerns
- To record consent before treatment begins
What it asks
- What is your name?
- What is your email address?
- What is your phone number?
- What is your main concern?
- How would you rate your sleep lately?
- How would you rate your digestion lately?
- How would you rate your energy lately?
- How would you rate your stress lately?
- What medications or supplements do you currently take?
- How do you feel about needles?
- I consent to acupuncture treatment and understand I can ask questions or stop at any time.
Why it should be encrypted
Answers may reveal health concerns, medications, and stress or sleep patterns. They should be readable only by the patient and the practitioner who needs them for care—not by SealForm or other unauthorized people.
Tips
- Tell patients how you’ll use their answers and who can access them.
- Add a question about allergies or relevant medical history if needed.
- Review the consent wording and treatment details before using the form.