An acupuncture intake form that asks about the herbs too

Free acupuncture intake forms that were not written for a physician office

Search for acupuncture intake forms and most of what comes back is a general medical history with the word acupuncture typed at the top. It asks about surgeries and prescriptions and stops, which means the single most relevant thing your client is taking often goes unrecorded. This preset was written for an acupuncture practice: what brings them in, how the complaint behaves through the day, sleep and digestion, energy and stress, and a proper record of everything they take rather than just the pharmaceutical half. Every field is editable and the acupuncture intake form PDF is available immediately, with no signup and no email wall.

• Built for HIPAA-compliant workflows

• Free to start — 50 patient actions each month

Medications, herbs and supplements each get their own rows

This is the section that makes an acupuncture new patient intake form worth its length. Clients routinely arrive taking a prescription from their physician, a herbal formula from a previous practitioner, and three supplements they bought themselves — and a form with a single medications line collects perhaps a third of that. Here each category repeats. Prescription medications with dose and prescriber. Herbal formulas with the name, who supplied it and how long they have taken it. Supplements and vitamins the same way. It takes the client no longer to complete, because they are copying from bottles either way, and it gives you a complete picture before they are on the table rather than halfway through a first treatment when something comes up in conversation.

What an acupuncture intake form usually covers

Contact and emergency details first, then the main complaint in the client's own words with onset, what makes it better or worse, and how it has changed. Relevant medical history, surgeries and injuries, with dates where they know them. The general health picture an acupuncture practice actually asks about: sleep quality and pattern, appetite and digestion, energy through the day, temperature preferences, stress and mood, and for many practices menstrual and reproductive history. Previous experience of acupuncture and how they responded. Then optional safety-history modules your practice can switch on — bleeding disorders and anticoagulant use, pacemakers or implanted devices, pregnancy status, and infectious disease history — which are off by default so you enable only what you have decided you need.

Edit it in plain language, download exactly what you built

Rename the form, rewrite any question or helper text, mark fields required or optional, switch the optional modules on or off, and add, duplicate, reorder or remove sections. Practices differ genuinely here — a sports and orthopaedic focused clinic and a fertility focused one ask quite different things after the first page. Treat this as an acupuncture intake form template rather than a finished document. A default PDF is ready as soon as the page loads, and after any change a new PDF is generated from your current version, so what you download matches what is on screen. It prints on US Letter with clean page breaks and real writing space, and reset restores the original preset.

A two-practitioner clinic, half an hour

A clinic with two licensed acupuncturists starts from this preset. They expand the herbal formula rows from three to six, having counted how many clients arrive on a formula from a previous practitioner. They add a question asking what the client has already tried for the complaint, including physiotherapy and medication, because it changes the conversation in the first session. They switch on the anticoagulant module and leave the infectious disease one off, judging it better handled verbally. They rewrite two questions into plainer English after a client asked what one of them meant. Half an hour, and the intakes start arriving complete.

Reported by the client, interpreted by the practitioner

Everything here is client-reported and recorded exactly as given. The form does not flag contraindications, detect interactions between a medication and a herbal formula, produce a pattern diagnosis, suggest points or a needling plan, or recommend a course of treatment — all of that is the professional judgement of a licensed acupuncturist, informed by an examination this document cannot perform. Informed consent is also deliberately a separate document rather than a paragraph bundled into the bottom of an intake form, because consent to treatment deserves its own signature and its own review. This is an original document written for this page rather than a copy of any published questionnaire or professional association form; where a body you belong to requires its own, use that one. Have a licensed practitioner review the clinical questions for your practice, and your attorney or professional insurer look at any policy wording you attach. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, and as this is a public tool, build the blank form here rather than entering real client details.