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New Patient Acupuncture Intake Assessment

Captures a new acupuncture patient's health history, presenting complaint, and treatment goals before their first visit, with an AI follow-up that probes the story behind their main complaint the way a practitioner would in an initial consult. Built for acupuncture and TCM clinics streamlining intake paperwork.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全15問・約8分
Q01
メッセージ

Welcome! Before your first acupuncture appointment, we'd like to understand your health history and what brings you in. This takes about 6-8 minutes and helps your practitioner prepare for your visit. Everything you share stays in your confidential patient record.

Q02
自由回答（短文）必須

What is the main health concern or reason you're seeking acupuncture treatment?

Q03
選択式必須

How long have you been experiencing this main concern?

  • Less than 1 week
  • 1-4 weeks
  • 1-6 months
  • 6-12 months
  • More than a year
Q04
オピニオンスケール必須

Right now, how would you rate the severity of this concern?

スケール: 0 – 10
最小:No symptoms at all最大:Worst imaginable
Q05
選択式

Have you tried any of the following for this concern before coming in?

  • Prescription medication
  • Over-the-counter medication
  • Physical therapy
  • Chiropractic care
  • Massage therapy
  • Prior acupuncture
  • Rest / no treatment
Q06
マトリクス必須

Please indicate whether you currently have any of the following:

7行 × 4列
  • Chronic pain (lasting 3+ months)
  • Digestive issues
  • Sleep problems
  • Anxiety or stress
  • Allergies
  • ほか2件
列: None · Mild · Moderate · Severe
Q07
自由回答（長文）必須

List any medications, supplements, or herbs you currently take, including dosage if known.

Q08
選択式必須

Do you have a pacemaker, are you pregnant, or do you have a bleeding disorder or metal allergy (relevant to needle placement)?

  • Pacemaker or implanted device
  • Currently pregnant
  • Bleeding disorder or blood thinner use
  • Metal allergy
  • Keloid scarring
Q09
選択式必須

Are you currently comfortable with needles, or is this a concern for you?

  • Comfortable, no concerns
  • Slightly nervous but willing to proceed
  • Significant fear of needles
  • This is my first time and I'm unsure how I'll react
Q10
オピニオンスケール必須

How would you rate your average stress level over the past month?

スケール: 1 – 7
最小:Very low stress最大:Very high stress
Q11
AIインタビュー

Reconstruct the story behind the respondent's main complaint: when it started, what makes it better or worse day to day, and how it affects their work, sleep, or daily activities. If they rated severity high or mentioned failed prior treatments, probe what specifically didn't work and what outcome would make this treatment feel successful. If they flagged needle anxiety, gently explore its source and what would help them feel safe.

Q12
選択式

What is your primary goal for acupuncture treatment?

  • Reduce or eliminate pain
  • Manage a chronic condition
  • Reduce stress or anxiety
  • Improve sleep
  • Support fertility or reproductive health
  • General wellness / maintenance
  • Other
Q13
選択式

What is your age range?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65+
  • Prefer not to say
Q14
選択式

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
メッセージ

Thank you for sharing this with us. Your responses will be added to your confidential patient file and reviewed by your practitioner before your visit to help personalize your treatment plan.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Goes beyond a static checklist by including an AI follow-up interview that reconstructs the story behind the patient's main complaint — when it started, what makes it better or worse, and how it's affecting them — the way a practitioner would probe in an initial consult.
  • Combines structured intake essentials (symptom duration, severity rating, current medications/herbs/supplements, contraindication screening for pacemakers/pregnancy/bleeding disorders, needle comfort) with open-ended narrative capture in one flow.
  • Screens for stress levels and prior treatments tried alongside a matrix of current conditions, giving practitioners a fuller clinical picture before the first visit.
  • Uses transparent, auditable prompts for the AI follow-up and can auto-generate a pre-visit report, rather than leaving the practitioner to manually parse free-text answers.

Jotform

Acupuncture Intake Form Template

A ready-to-use, customizable intake form built specifically for acupuncture practices, covering standard fields like patient details and health history. It's a static form builder template rather than an interview — there's no mechanism to ask a patient a dynamic follow-up about their specific complaint. Strong choice for clinics that just need a clean digital paperwork replacement.

優れている点

  • Purpose-built for acupuncture practices specifically, not a generic medical intake
  • Easy to customize within Jotform's drag-and-drop form builder
  • Likely integrates with Jotform's broader forms/e-signature ecosystem

物足りない点

  • Static field-based form with no adaptive follow-up questioning on the patient's presenting complaint
  • No published quality-scoring or automated report generation from responses
  • No transparent prompt/methodology documentation since there's no AI component

Typeform

Acupuncture Intake Form Template

A conversational, one-question-at-a-time intake template in Typeform's signature style, well-suited to a friendlier patient intake experience than a traditional form. It still relies on pre-set question logic rather than a real-time AI probing the patient's story. Good for clinics prioritizing a polished, on-brand intake feel over deeper narrative capture.

優れている点

  • Conversational, guided question flow that feels less clinical than a paper form
  • Typeform's polished design and branding customization
  • Simple to deploy and share as a pre-visit intake link

物足りない点

  • No adaptive AI interview to dig into the story behind the main complaint — only fixed question branching
  • No automated per-response quality scoring or auto-generated clinical summary report
  • No published prompt transparency since responses aren't AI-interpreted

よくあるご質問

「New Patient Acupuncture Intake Assessment」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が15問含まれており、最初の設問は次のとおりです：「Welcome! Before your first acupuncture appointment, we'd like to understand your health history and what brings you in.…」・「What is the main health concern or reason you're seeking acupuncture treatment?」・「How long have you been experiencing this main concern?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、15問を約8分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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