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Acupuncture intake form

Western history and the questions only an acupuncturist asks, on one form, answered before the first appointment.

Free, and no account needed to start. Send the link however you normally would: text, email, or a group chat. People fill it in on their phones. Sort the answers, search them, download them as a spreadsheet. 100 replies a month on the free plan.

Or download the printable PDF. Free, no email address, ready to print and pin up.

Already have your own version? Upload it and keep your wording.

The form people fill in, and the list you get back

This is the real form, not a screenshot of one, and it works. Below it is what you see as the answers come in.

Acupuncture intake and consent

31 questions · takes about 8 min

How long has this been going on?
Have you had acupuncture before?
Do any of these apply to you?

Select all that apply.

How is your sleep?
How is your energy through the day?
How would you describe your stress at the moment?
Do you tend to feel more hot or more cold than people around you?
Signature
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By signing here I agree that this signature, and the answers submitted with it, are mine and have the same effect as a signature on paper.

All 31 questions

  1. Full name (required)
  2. Pronouns
  3. Date of birth (required)
  4. Phone number (required)
  5. Email address (required)
  6. Date of first appointment (required)
  7. Practitioner
  8. Emergency contact — name and relationship (required)
  9. Emergency contact — phone number (required)
  10. What brings you in? (required)
  11. How long has this been going on? (required)
  12. If it is painful, how would you rate it today, 0 to 10?
  13. What have you already tried?
  14. Have you had acupuncture before? (required)
  15. Do any of these apply to you? (required)
  16. Diagnosed conditions, past and present
  17. Medications and supplements (required)
  18. Allergies
  19. Operations and significant injuries
  20. How is your sleep?
  21. How is your digestion and appetite?
  22. How is your energy through the day?
  23. How would you describe your stress at the moment?
  24. Do you tend to feel more hot or more cold than people around you?
  25. I understand treatment involves sterile single-use needles and may include cupping, moxibustion or gua sha unless I say otherwise (required)
  26. I understand the common effects: minor bruising, brief soreness, temporary tiredness and, rarely, light-headedness (required)
  27. I understand acupuncture is not a substitute for medical diagnosis or treatment, and that I should continue any care my doctor has prescribed (required)
  28. I understand I may ask the practitioner to stop or adjust at any point (required)
  29. The information above is accurate and I will tell my practitioner if it changes (required)
  30. Signature (required)
  31. Date (required)

You can reword any of these, or add your own, after you create it.

An example of what you see when answers come in, with three replies
20 Aug, 16:03Wren Hallidaythey/them1997-02-09(503) 555-0176wren.h@example.com2026-08-24M. Oyelaran, LAcRobin Halliday, parent(360) 555-0114Migraines, two or three a week since spring. Light and screens set them off.One to six months7Sumatriptan, works about half the time. Cut out caffeine, no change.Yes, and it helpedFainting or feeling faint with needlesMigraine with auraSumatriptan as needed, propranolol 40mgNickel — rashNonePoor in several waysNauseous with the migrainesVariableVery highBoth, at different timesYesYesYesYesYes2026-08-20
19 Aug, 09:47Desmond Achebehe/him1966-12-01(971) 555-0121d.achebe@example.com2026-08-22J. Tanaka, LAcIfy Achebe, wife(971) 555-0159Neuropathy in both feet, worse at night. Diabetic for eleven years.Longer than five years5Gabapentin, helps a little. Nothing else.Yes, it was mixedDiabetes, Taking a blood thinner or anticoagulantType 2 diabetes, hypertension, atrial fibrillationMetformin, apixaban, gabapentin 300mg at night, ramiprilNone knownCataract, both eyes, 2023Trouble falling asleepGood appetiteLow most of the timeManageableMore hotYesYesYesYesYes2026-08-19
18 Aug, 19:22Órla Ní Bhriainshe/her1983-05-17(503) 555-0143orla.nb@example.com2026-08-21J. Tanaka, LAcCillian Ní Bhriain, brother(503) 555-0188Lower back, right side, since a fall in March. Worse sitting, better walking.One to six months6Physio for eight weeks — helped for a day or two after each session, then back. Ibuprofen.No, this is my first timeNone of theseNoneIbuprofen as neededNone knownNoneWaking in the nightFine, no changesAfternoon dipHighMore coldYesYesYesYesYes2026-08-18

Scroll sideways for the rest of the 31 answers, and press any heading to sort by it. In your own form you can search the answers as well, and download them as a spreadsheet at any time.

Two of the screening answers change the treatment plan, not the appointment

Pregnancy changes which points may be used rather than whether treatment happens. A pacemaker or implanted electrical device rules out electroacupuncture and nothing else. Both are routinely discovered mid-session because nobody asked, and both are one tick box.

Bleeding disorders, anticoagulants and immunosuppressants are the ones that change depth, technique and aftercare. Lymphoedema or removed lymph nodes rules out needling that limb. Fainting with needles is not a contraindication but it decides whether the first treatment is done lying down.

Ask what they already tried, and whether it worked

"Six months of physiotherapy, no change" and "physiotherapy helped for a fortnight each time" point in different directions, and neither is captured by a list of past treatments. The follow-up — did it help — is the half that is usually missing and usually the more useful.

It also tells you where you sit in the sequence. Somebody who has tried nothing and somebody who has tried everything are the same complaint and different appointments.

The sleep, digestion, energy and temperature questions are not padding

A western intake form asks what is wrong. A traditional Chinese medicine assessment asks how the whole system is behaving, and sleep pattern, appetite, energy through the day and whether somebody runs hot or cold are four of its standard inputs.

Asking them as short structured questions rather than an open history gets them answered. "How is your sleep?" with five options gets a usable answer from somebody who would write "fine" in a box.

Consent covers what else might be used

Clients book acupuncture and are then offered cupping, moxibustion or gua sha, all of which can leave visible marks for days. Naming them in the consent — with the option to decline — prevents the conversation that starts "nobody told me I would have circles on my back".

Sent ahead, this is a shorter first appointment

A full intake takes fifteen to twenty minutes of a first session that is often sixty. Answered at home it takes the client longer and the practitioner none, and the medication answer is accurate because the boxes are on the table.

If your practice already uses its own intake form, upload that PDF rather than this one — the questions are read off the document and your wording, your point vocabulary and any state-required language stay as they are.

What this is not

A starting point, not a clinical or legal document, and this service is not offered as a HIPAA-covered platform — there is no business associate agreement. Licensing, scope and record retention for acupuncture are set by state boards and differ considerably. Check what applies where you practise.

Questions people ask

What should an acupuncture intake form include?

Contact details and an emergency contact, the presenting complaint in the client's own words with how long it has lasted and what has already been tried, previous experience of acupuncture, a screening list covering pregnancy, pacemakers, bleeding disorders, anticoagulants, immunosuppressants, seizures, fainting with needles, diabetes and lymphoedema, medications and allergies, the standard TCM questions on sleep, digestion, energy, stress and temperature, and consent covering needles, adjunct techniques such as cupping and moxibustion, common effects and the right to stop.

Who should not have acupuncture?

Very few people outright. Most of the screening list changes the treatment rather than preventing it: pregnancy changes which points are used, a pacemaker rules out electroacupuncture, lymphoedema rules out needling that limb, and anticoagulants change depth and aftercare. Active skin infection at the site is the common local contraindication.

Why does an acupuncture form ask about sleep and digestion?

Because a traditional Chinese medicine assessment reads the whole system rather than the complaint alone, and sleep pattern, appetite, daily energy and whether somebody runs hot or cold are four of its standard inputs. Asking them as short structured questions gets them answered; asking for an open history does not.

Should the consent mention cupping and moxibustion?

Yes. Clients book acupuncture and are then offered adjunct techniques that can leave visible marks for several days. Naming them, with the option to decline, prevents the most common complaint a clinic hears.

Is this acupuncture intake form free?

Yes. Download the printable PDF with no account and no email address, or send the online version ahead of the first appointment.

Ready to send it out?

Every question above is already written. Make it a form, get your link, and send it. Reword anything first if your group asks it differently.

Free, no account needed to start, and the printable PDF stays one click away.

Already have your own version of this form?

You build nothing. Drop the PDF here, or photograph the printed copy, and the questions are read off it: no canvas, no dragging a box onto each field, no mapping step. The wording your organisation already approved stays exactly as it is, and you get a link that collects the answers back as a spreadsheet — and as the original document, filled in.

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