Download Acupuncture Intake Form

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The Acupuncture Intake Form must first take in such prosaic information as the patient’s name, address, height, weight, gender, and the name of his or her primary care physician. It should also ask why the patient is seeking to undergo acupuncture, and, for marketing purposes, how the patient learned of your practice.

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How to Fill-in

Since most people come to acupuncturists because they are experiencing pain, the Acupuncture Intake Form will include a space for detailing that pain, it’s severity and its type. If the cause of the pain is known, that cause should be noted. If there is anything that the patient does that can, at least temporarily, alleviate the pain, the form should have space to register that information as well. The form must also have a block of space to note how this pain impacts on the patient’s life, and if any work or leisure activities are affected.

The form should next have space to list any previous acupuncture treatments, the dates on which they occurred, the name and address of the provider, and the results of the treatments.

The Acupuncture Intake Form next needs to document the state of the patient’s general health. There should be ample space to document any prescription drugs, and also any over-the-counter medications that the patient regularly takes.

A properly detailed Acupuncture Intake Form will also have a list of the common ailments, with boxes to check-off if the patient suffers from it. Major medical problems must be noted, and those specific issues and symptoms that may be cured or at least alleviated through acupuncture should be listed.

A bit more space must be set aside to describe any problems that the patient has with headaches or dizziness. Problems with vision and hearing are also of concern to acupuncturists, so they, too, must be logged.

Because Alcohol, tobacco and caffeine have such a large effect on an individual’s health, the Acupuncture Intake Form will document the patient’s consumption of each. The type and frequency of exercise is to be described, as well as the patient’s eating habits. For treating female patients, knowledge of any menstrual issues are very important, and they, too, need to be documented on this form.

Because of their relevance to the acupuncturist, space to list the patient’s preference for hotter or colder weather, as well as preferences for milder or spicier foods should be included. The acupuncturist will also want to include his or her assessment of the patient’s energy level.

If the patient’s insurance covers acupuncture, insurance information must be listed. And the insurance company must be directed, via the patient’s dated signature, to release payments to you, the acupuncturist.

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