Acupuncture Clinic New Patient Intake

Acupuncture Clinic New Patient Intake — Form Fields

This healthcare template includes 12 fields. New patient intake form for traditional acupuncture and Chinese medicine clinics. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Home Address (text, required)
• Primary Reason for Visit (dropdown selection, required) — options: Pain Management, Stress/Anxiety, Digestive Issues, Fertility, Headaches/Migraines, Insomnia, Allergies, General Wellness
• Areas of Pain or Discomfort (checkboxes, optional) — options: Head/Neck, Shoulders, Upper Back, Lower Back, Hips, Knees, Hands/Wrists, Feet/Ankles
• How Long Have You Had This Condition (dropdown selection, required) — options: Less Than 1 Month, 1-3 Months, 3-6 Months, 6-12 Months, Over 1 Year
• Previous Acupuncture Experience (multiple choice, required) — options: Yes, No
• Current Medications (text, optional)
• Medical History Summary (long text, required)
• Are You Pregnant (multiple choice, optional) — options: Yes, No, Possibly