Acupuncture intake form
An acupuncture intake form gathers what a patient is seeking treatment for and what medications they take, so the practitioner knows the context before the appointment. Pain level and prior experience help shape how the treatment is explained and performed.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
Pain level as a slider field, not words
A 0-10 slider gives the practitioner a comparable number across patients. "Quite a bit of pain" or "moderate discomfort" is subjective; 6 or 7 on a scale is objective and faster to interpret.
Medications as open text, not a checkbox list
Patients are on many different medications, so a free text field for current medications is what catches interactions or contraindications the practitioner needs to know. A fixed checkbox list would miss half the medications.
No card required.
Acupuncture Intake Form
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add short text, email and phone fields for the patient's name and contact details.
- Add a long text field for reason for visit — what brought the patient in, what they hope treatment will help with.
- Add a text field for current medications, left optional, because not every patient takes any.
- Add a slider field for pain level, set to 0-10, so the practitioner sees a structured number instead of parsing descriptions.
- Add a radio group for prior acupuncture experience: first time, some experience, regular patient. This shapes how the practitioner explains the treatment.
Fields in this form
7 fields, using 6 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Full name | Short text | Yes |
| Yes | ||
| Phone | Phone | Yes |
| Reason for visit | Long text | Yes |
| Current medications and supplements | Long text | Optional |
| Current pain level (0 = none, 10 = severe) | Slider | Yes |
| Prior acupuncture experience | Radio buttons | Yes |
What goes wrong with this form
Specific to a acupuncture intake form, not general advice about forms.
Treating the intake as a diagnosis tool
This form collects information for the appointment; it does not diagnose anything. The practitioner evaluates everything in person and makes clinical decisions about treatment. Assuming an intake form's answers mean anything definitive is a misuse.
Pain level as a text field
Use a slider field set to 0-10 rather than asking "how much pain". A number — 4, 7, 9 — is faster to read and comparable across patients; text fields produce "moderate", "quite bad", "unbearable" that do not sort or average.
Medications as a checkbox list
Patients take too many different medications for a fixed list. An open text field for current medications is what catches the ones that matter for acupuncture treatment without missing anything because it's not on the list.
Questions about this form
What is an acupuncture intake form used for?
It collects what the patient is seeking treatment for, what medications they take, their pain level, and whether they've had acupuncture before. This is a general intake, not a medical or clinical diagnosis. The practitioner evaluates everything in person and makes treatment decisions based on what they see and feel.
Is this form the same as a medical history?
No. This intake form is an information sheet for the acupuncture appointment. It is not a substitute for a full medical history or a doctor's evaluation. The practitioner remains responsible for professional judgment about whether acupuncture is appropriate for this patient.
What should I list for current medications?
List any medications you're currently taking, including over-the-counter ones, supplements and herbal remedies. The practitioner needs to know because some interact with acupuncture treatment or may affect how you respond.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Appointment Request FormCollect a preferred date, time and reason for visit for clinics, salons and studios.
- Medical HistoryCollect a new patient's medical background before the first appointment.