Q01
메시지
모든 템플릿
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.
샘플 질문
템플릿에 포함된 내용을 미리 확인해 보세요. 모든 질문은 설문 공개 전에 자유롭게 수정할 수 있습니다.
질문 15개 · 약 8분
Q02
단문형필수
What is the main health concern or reason you're seeking acupuncture treatment?
Q03
객관식필수
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
의견 척도필수
Right now, how would you rate the severity of this concern?
척도: 0 – 10
최소:No symptoms at all최대:Worst imaginable
Q05
객관식
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
매트릭스필수
Please indicate whether you currently have any of the following:
7개 행 × 4개 열
- Chronic pain (lasting 3+ months)
- Digestive issues
- Sleep problems
- Anxiety or stress
- Allergies
- 외 2개
열: None · Mild · Moderate · Severe
Q07
장문형필수
List any medications, supplements, or herbs you currently take, including dosage if known.
Q08
객관식필수
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
객관식필수
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
의견 척도필수
How would you rate your average stress level over the past month?
척도: 1 – 7
최소:Very low stress최대:Very high stress
Q11
AI 인터뷰
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
객관식
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
객관식
What is your age range?
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65+
- Prefer not to say
Q14
객관식
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q15
메시지
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.
포함된 기능
AI 후속 질문
정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.
주의력 확인 장치
성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.
AI가 작성한 문안
문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.
자동 리포트
응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.
다른 서비스와 비교
다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.
이 템플릿을 선택하는 이유
- 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 TemplateA 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.
잘하는 점
- 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
아쉬운 점
- 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 TemplateA 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.
잘하는 점
- 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
아쉬운 점
- 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
설문을 공개할 준비가 되셨나요?
이 템플릿을 편집기에서 열어 보세요. 첫 응답자가 보기 전에 모든 부분을 원하는 대로 바꿀 수 있습니다.