What is the acupuncture intake form template?
Before inserting a needle, an acupuncturist needs to know about bleeding disorders, blood thinners, implanted devices, pregnancy, fainting and skin conditions — as well as the problem the client wants help with. This intake form asks all of it in plain language, then records the client's consent to needling and any additional techniques.
The first half is about the client's goals: the main complaint, how long it has lasted, severity on a 0–10 scale, what makes it better or worse and other treatment tried, plus sleep, energy and stress. The health history page has a single screening checklist for the conditions that matter most for needling, a pregnancy question with a weeks field, medication, allergies and previous acupuncture experience.
Signed forms are saved as PDFs in your FileIt vault, so every client's history and consent are on file before their first session.
- Best for
- Acupuncturists, integrative clinics and physiotherapists who use dry needling
- Filled in by
- The client, before their first treatment
- Time to complete
- About 8 minutes
- Includes
- Presenting complaint scales, needling screening checklist, pregnancy question, technique consent, signature
Who uses a acupuncture intake form?
- New client intake for a private acupuncture practice
- Screening before dry needling in a physiotherapy clinic
- Fertility or pregnancy acupuncture where weeks of pregnancy matter
- Multi-practitioner clinics that want one consistent consent record
- Refreshing health history for returning clients once a year
- Pain clinics offering acupuncture alongside other treatment
Questions on this acupuncture intake form
31 questions over 4 pages · includes signature, conditional questions, multiple pages, consent checkbox, ratings.
1 Your details
- Name*
- Date of birth*
- Phone*
- Email*
- Address
- Emergency contact name*
- Emergency contact phone*
2 What brings you in
- What would you like help with?*
- How long have you had it? Less than a month · 1–3 months · 3–12 months · 1–5 years · More than 5 years
- How severe is it at the moment?
- What makes it better or worse?
- Other treatment you've had or are having for this
- How is your sleep? Good · Fair · Poor
- How is your energy? Good · Fair · Low
- Your stress level lately
- What would a good result look like for you?
3 Health history
- Do any of these apply to you?* Pacemaker or other implanted electrical device · Bleeding or clotting disorder · Taking blood-thinning medication · Diabetes · Epilepsy or seizures · Heart condition · Very high or low blood pressure · Blood-borne infection (e.g. hepatitis B or C, HIV) · Weakened immune system · Skin condition or broken skin in the area to be treated · Metal allergy · Fainting or strong fear of needles
- Anything you'd like to tell us about the conditions ticked?
- Are you pregnant or trying to conceive? No · Yes, pregnant · Trying to conceive · Not applicable
- How many weeks pregnant? asked only when it applies
- Current medication and supplements
- Allergies
- Surgery, injuries or hospital stays in the last two years
- Doctor / GP name and practice
- Have you had acupuncture before?
- How did you find it? asked only when it applies
4 Consent
- Other techniques you're happy to receive if your practitioner suggests them Electro-acupuncture · Moxibustion (warming with a herb) · Cupping · Gua sha · None — needling only
- Health information*
- Consent to treatment*
- Signature*
- Date*
The acupuncture intake form, page by page
1 Your details
Name, date of birth, phone, email and address, plus a required emergency contact name and phone.
2 What brings you in
The main complaint in the client's words, how long they've had it and a 0–10 severity scale, what makes it better or worse and other treatment tried. Sleep, energy and a stress scale give general context, and a last question asks what a good result would look like.
3 Health history
One checklist covers pacemakers and implanted devices, bleeding disorders and blood thinners, diabetes, epilepsy, heart conditions, blood pressure, blood-borne infections, weakened immunity, skin problems, metal allergy, needle fainting and cancer — with a free-text box for detail. Pregnancy is asked separately, with a weeks field if pregnant. Medication, allergies, recent surgery, GP details and previous acupuncture experience complete the page.
4 Consent
A short explanation of what acupuncture involves and its common short-lived effects. The client ticks any additional techniques they're happy to receive — electro-acupuncture, moxibustion, cupping or gua sha — confirms their health information is accurate, consents to treatment, signs and dates.
Make the template yours
- Edit the screening checklist to match your professional body's guidance
- Remove techniques you don't offer from the additional techniques list
- Add your cancellation policy as another consent statement
- Add a body diagram upload or a question about pain location if you use one
- Set the confirmation message to include what to wear and eat before a session
- File each client's intake into their own folder in your vault
Tips for a better acupuncture intake form
- Review the screening checklist before every first session, not just when something is ticked
- Recheck pregnancy and medication at later visits — circumstances change
- Ask about needle fainting early and treat nervous clients lying down
- Use the severity scale again at follow-ups to track progress
- Have your consent wording checked against your own insurance and regulatory requirements
Every response becomes a PDF in your vault
The completed intake is saved as a signed PDF in your FileIt vault and you're notified by email. The client can receive a copy of what they signed.
The Responses table lists new clients waiting for their first appointment; CSV export is available if you need it.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Acupuncture intake form: frequently asked questions
Is this acupuncture intake form free?
Yes. It's included in the Forms app on every FileIt account, including the free plan.
Does it screen for contraindications to needling?
It asks about the conditions most practitioners want to know about — implanted devices, bleeding disorders and blood thinners, pregnancy, epilepsy, skin problems and more. Your clinical judgement still decides whether and how to treat.
Can I use it for dry needling?
Yes. Rename it and adjust the wording and techniques list in the designer.
Is the consent wording legally sufficient?
It's a plain-language starting point. Check it with your professional association or insurer for your jurisdiction.
Does the client need an account to sign?
No. They sign on screen from the link you share, without an account.
Where is the signed form kept?
It's saved as a PDF in your FileIt vault and listed in the form's responses.