Template library · Intake forms
Acupuncture Intake template
Please complete before your first acupuncture session.
- 20 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Contact Info
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Emergency contact (name & phone)Text
Health History
- What brings you in today?Text
- OtherText
- Current medications & supplementsText
- Allergies (including to metals/latex)Text
- Current pain levelText
- Do you have any of the following? (check all that apply):
- Diabetes
- Heart condition
- Bleeding disorder
- Pacemaker
- Pregnant
- Epilepsy/seizures
TCM Assessment
- How would you describe your sleep?Choice
- Stress levelText
- Digestion / appetite notesText
- Menstrual cycle notes (if applicable)Text
- Have you had acupuncture before?Choice
- Treatment goalsText
- Client signatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
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