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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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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

15 questions · ~8 min
Q01
Message

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
Short TextRequired

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

Q03
Multiple ChoiceRequired

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
Opinion ScaleRequired

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

Scale: 0 – 10
Min:No symptoms at allMax:Worst imaginable
Q05
Multiple Choice

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
MatrixRequired

Please indicate whether you currently have any of the following:

7 rows × 4 columns
  • Chronic pain (lasting 3+ months)
  • Digestive issues
  • Sleep problems
  • Anxiety or stress
  • Allergies
  • +2 more
Columns: None · Mild · Moderate · Severe
Q07
Long TextRequired

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

Q08
Multiple ChoiceRequired

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
Multiple ChoiceRequired

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
Opinion ScaleRequired

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

Scale: 1 – 7
Min:Very low stressMax:Very high stress
Q11
AI Interview

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
Multiple Choice

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
Multiple Choice

What is your age range?

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

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
Message

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.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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