Acupuncture Intake Form

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An acupuncture intake form is a form provided by acupuncture clinics to collect new patients’ information. The form gathers the patient’s contact information, symptoms, health concerns, and any history of injuries or treatments. Intake forms help clinics by streamlining the process of diagnosing and treating their patients’ health concerns.

Acupuncture Intake Form

An acupuncture intake form is a form provided by acupuncture clinics to collect new patients’ information. The form gathers the patient’s contact information, symptoms, health concerns, and any history of injuries or treatments. Intake forms help clinics by streamlining the process of diagnosing and treating their patients’ health concerns.

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Last updated September 17th, 2024

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An acupuncture intake form is a form provided by acupuncture clinics to collect new patients’ information. The form gathers the patient’s contact information, symptoms, health concerns, and any history of injuries or treatments. Intake forms help clinics by streamlining the process of diagnosing and treating their patients’ health concerns.

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Acupuncture Treatment

Acupuncture is a practice in traditional Chinese medicine (TCM) in which needles are inserted at precise points in the patient’s body. It is generally used to relieve and treat pain, headaches, stress, fibromyalgia, and other physical and mental ailments.

What’s Collected

General Patient Information

This section records the patient’s basic information, including their contact details, occupation, marital status, and emergency contact’s name and phone number.

Health Concerns

The patient should describe the issue that has brought them to the clinic, including how it affects day-to-day activities, how long they’ve experienced symptoms, and where exactly on their body they’re experiencing symptoms. They should also specify any allergies, previous injuries, and medications or supplements they are taking.

Acknowledgment and Consent

An intake form should describe the treatment and the associated risks. It should also have the patient sign and acknowledge that they understand the risks, give their consent, and release the clinic/acupuncturist of liability for injuries.

Acupuncture Licensing & Regulation

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) provides the certification necessary for acupuncturists in nearly every state[1].
In addition to certification, practitioners will need a state license to operate. Though licensing requirements vary, most state authorities will require that an applicant[2]:
  • Is at least 18 or 21 years old.
  • Has passed the NCCAOM exams and/or holds certification.
  • Holds a university or college degree in a related field.
  • Is CNT certified (clean needle technique).
  • Pays the licensure fee.

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