Acupuncture Intake Form

Acupuncture Intake Form

Last updated July 11th, 2023

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An acupuncture intake form is a form provided by acupuncture clinics to collect new patients’ information. The form collects 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 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.

Form Components

Patient General 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, medications, or supplements they are taking, and any previous injuries they’ve had.


The form will require the patient’s printed name, signature, and signing date.

Acupuncture Licensing & Regulation

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) provides certification required for acupuncturists in nearly every state. Though licensing requirements vary across states, applicants are generally required to be at least 18 or 21 years old, hold the NCCAOM certification, complete a university or college program (often in a specific field such as bioscience), and pay the required fee.

Acupuncturists in California must be licensed by the state Acupuncture Board or the Medical Board of California if they are physicians seeking to practice acupuncture.