Acupuncture Intake Form With a TCM Symptom Checklist

The form itself

A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.

New patient form

Golden Needle Clinic. Please complete before your first treatment. Several questions will look unrelated to why you booked. They are the questions a traditional diagnosis is built from, so answer them as they come.

About you

Your name *

First

Last

Date of birth *

Best phone number *

Email *

Why you are here

What is the main thing you want treated, and how long has it been going on? *

The traditional questions

The next five questions are the ones a practitioner of Chinese medicine asks everybody, whatever they came in for. Temperature, thirst, digestion, sleep and the menstrual cycle are read together as a pattern. Your answers are health information and are read only by your practitioner.

Do you run hot or cold compared with people around you? *

Always cold, first to put a jumper on

Cold hands and feet, but otherwise comfortable

About the same as everyone else

Warm, first to open a window

Hot at night, comfortable by day

It swings between the two

Which of these do you notice most weeks? *

Dry mouth or constant thirst

Prefer hot drinks, rarely thirsty

Night sweats or waking damp

Dizziness on standing

Ringing in the ears

Palpitations or a racing heart

Low back or knee ache

Headaches behind the eyes or at the temples

Sighing, or a tight chest when stressed

Bruise easily

None of these

Digestion: what happens on a normal week? *

Bloating after meals

Appetite comes and goes

Hungry again an hour later

Heartburn or reflux

Loose stools or urgency

Constipation

Worse when stressed

Worse after cold or raw food

Nothing unusual

How do you sleep? *

Straight off, through until morning

Take an hour or more to get off

Wake between one and three, then lie awake

Wake early and cannot get back

Wake often through the night

Vivid dreams, wake unrefreshed

Menstrual cycle, if this applies to you

Needling safety

Do any of these apply to you? *

Taking blood thinning medication

A bleeding disorder such as haemophilia

A pacemaker or another implanted electrical device

Pregnant, or trying to conceive

Immune system suppressed by medication or illness

Lymph nodes removed on one side

Metal allergy, including nickel

Faint at the sight of needles or blood

Epilepsy

None of these

Medications, supplements and herbs you take

Have you had acupuncture before? *

Never

Once or twice

A full course at some point

Regularly, with another practitioner

Yes, and I reacted badly to it

Consent

Treatment uses single use sterile needles, opened in front of you and disposed of after one insertion. Common and harmless responses are a dull ache at the point, brief light headedness, tiredness for a few hours and a small bruise. Rare risks are discussed before any technique near the chest or upper back. Cupping and moxibustion may be offered and can be declined, as can any point, at any time and without giving a reason.

Consent to needling *

I have read the statement above and consent to acupuncture treatment

Signature *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your nameNameRequired
Date of birthDateRequired
Best phone numberShort textRequired
EmailShort textRequired
What is the main thing you want treated, and how long has it been going on?Long textRequired
Do you run hot or cold compared with people around you?Single choiceRequired: Options: Always cold, first to put a jumper on · Cold hands and feet, but otherwise comfortable · About the same as everyone else · Warm, first to open a window · Hot at night, comfortable by day · It swings between the two
Which of these do you notice most weeks?Multiple choiceRequired: Options: Dry mouth or constant thirst · Prefer hot drinks, rarely thirsty · Night sweats or waking damp · Dizziness on standing · Ringing in the ears · Palpitations or a racing heart · Low back or knee ache · Headaches behind the eyes or at the temples · Sighing, or a tight chest when stressed · Bruise easily · None of these
Digestion: what happens on a normal week?Multiple choiceRequired: Options: Bloating after meals · Appetite comes and goes · Hungry again an hour later · Heartburn or reflux · Loose stools or urgency · Constipation · Worse when stressed · Worse after cold or raw food · Nothing unusual
How do you sleep?Single choiceRequired: Options: Straight off, through until morning · Take an hour or more to get off · Wake between one and three, then lie awake · Wake early and cannot get back · Wake often through the night · Vivid dreams, wake unrefreshed
Menstrual cycle, if this applies to youShort text
Do any of these apply to you?Multiple choiceRequired: Options: Taking blood thinning medication · A bleeding disorder such as haemophilia · A pacemaker or another implanted electrical device · Pregnant, or trying to conceive · Immune system suppressed by medication or illness · Lymph nodes removed on one side · Metal allergy, including nickel · Faint at the sight of needles or blood · Epilepsy · None of these
Medications, supplements and herbs you takeLong text
Have you had acupuncture before?Single choiceRequired: Options: Never · Once or twice · A full course at some point · Regularly, with another practitioner · Yes, and I reacted badly to it
Consent to needlingMultiple choiceRequired: Options: I have read the statement above and consent to acupuncture treatment
SignatureSignatureRequired

What each block of this form collects

Four identity fields, then one open question about the complaint, and then the part that makes this an acupuncture form rather than a generic health questionnaire. The traditional block is introduced by a paragraph that tells the patient plainly why they are about to be asked whether they prefer hot drinks, because a question that looks like a non sequitur gets a careless answer unless its purpose is stated. Temperature comes first, then the eleven sign checklist, then digestion, then sleep, then the cycle question for the patients it applies to. The safety block is separate and is read differently: it is not a pattern, it is a list of nine conditions that change where needles go, how deep they go, or whether a point is used at all. The consent paragraph describes what the patient will actually feel.

How to adapt this form

A fertility focused clinic promotes the cycle question out of a single short text field into its own block: cycle length, basal temperature charting, previous cycles tracked, and any assisted reproduction already under way, because that detail is the case rather than a footnote to it. A musculoskeletal practice keeps the safety screen intact but replaces the traditional block with a body region tick list, a side, an onset date and an aggravating factor list, since dry needling patients come with an injury rather than a pattern. A clinic that also does cosmetic acupuncture adds a facial history question, previous injectables and threads included, which matters because recent filler changes where needles can safely be placed.

What makes this form work

The odd questions are explained before they are asked

A paragraph above the block says these five are asked of everybody and are read together as a pattern. Without it, a patient who came about a shoulder answers a thirst question carelessly, and the whole traditional section becomes decorative.

Safety is a separate block with nine named conditions

Blood thinners, bleeding disorders, a pacemaker, pregnancy, immune suppression, lymph node removal, metal allergy, fainting and epilepsy. Each one changes depth, point selection or positioning, and none of them belongs mixed in with a diagnostic pattern.

The sleep question describes nights, not hours

Waking between one and three then lying awake is a different answer from taking an hour to get off, and both are different from vivid dreams and waking unrefreshed. Six described nights collect more than any number of hours slept ever would.

Questions people ask

Why does an acupuncture form ask whether I run hot or cold?

Because it is one of the oldest diagnostic questions in Chinese medicine and it sorts patients before anything else does. Somebody who is always cold and prefers hot drinks is treated differently from somebody who is hot at night and thirsty for cold water, even when they arrive with the same shoulder. Six options cover it in one tap.

What happens if I tick blood thinners on the safety screen?

The treatment changes rather than stopping. Needling still goes ahead, with finer needles, fewer points, shallower insertion and longer pressure afterwards, and the practitioner will mention that a small bruise is more likely. The point of asking on the form is that the adjustment is planned before the patient is on the table.

Why is the menstrual question optional and unstructured?

Because it does not apply to every patient and forcing it produces noise. As a single optional short text field it invites cycle length, days of bleeding, pain, clots and the date of the last period from the people it is relevant to, and it is skipped silently by everyone else. A practitioner who needs more asks in the room.

Does the form record whether needles have been used before?

Yes, as a five option question that ends with a bad reaction. Never, once or twice, a full course, regularly elsewhere, and reacted badly are five different first treatments. The last option is the one that changes the session most, because it prompts a conversation before a single needle is opened.

What does the consent paragraph say will happen?

That needles are single use and sterile, opened in front of the patient and thrown away after one insertion, and that a dull ache at the point, brief light headedness, a few hours of tiredness and a small bruise are common and harmless. It also names cupping and moxibustion as offers that can be declined, as can any individual point.

Is this form suitable for a dry needling physiotherapist?

Partly. The safety screen transfers unchanged and is the most valuable block for any needling practitioner. The traditional questions do not, since dry needling works from a musculoskeletal assessment rather than a pattern, so that block would be replaced with a body region list, a side and an onset date.

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