← All templates

Acupuncture Health History Form template

A free acupuncture health history form with main concern, sleep, energy, digestion, temperature, stress, and needle safety screening. Includes a consent section patients sign online.

Acupuncture Health History Form

About you

Full name *

Date of birth *

Phone number *

Email address *

Main concern

What would you like help with? *

How long have you had this concern? *

How much does it affect your daily life? (0 = not at all, 10 = completely) *

Have you had acupuncture before? *

How did you respond to it? *

General health

How is your sleep? *

How is your energy through the day? *

How is your appetite and digestion? *

Do you tend to feel hot or cold? *

Stress level (0 = none, 10 = extreme) *

Safety screening

Do any of these apply to you? *

Current medications and supplements

Allergies

Consent

Acupuncture uses sterile, single-use needles. Possible side effects include minor bruising, soreness, or lightheadedness. I will tell my practitioner if I feel unwell during treatment.

I understand and consent to acupuncture treatment *

Signature — type your full legal name *

Date signed *

What to ask on an acupuncture intake

  1. Main concern and duration
  2. Prior acupuncture response
  3. Sleep quality
  4. Energy through the day
  5. Appetite and digestion
  6. Hot or cold tendency
  7. Bleeding risk and implants
What's included
  • Full name
  • Date of birth
  • Phone number
  • Email address
  • What would you like help with?
  • How long have you had this concern?
  • How much does it affect your daily life? (0 = not at all, 10 = completely)
  • Have you had acupuncture before?
  • How did you respond to it?
  • How is your sleep?
  • How is your energy through the day?
  • How is your appetite and digestion?
  • Do you tend to feel hot or cold?
  • Stress level (0 = none, 10 = extreme)
  • Do any of these apply to you?
  • Current medications and supplements
  • Allergies
  • I understand and consent to acupuncture treatment
  • Signature — type your full legal name
  • Date signed
Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.