Form templates
Intake form templates for acupuncture practices.
Start from a form written for a treatment room, not a generic clinic. Preview any of them live, then add one to Goji and make it yours.
Starting points, not legal or medical advice. Read the full note
Intake forms
What a new patient fills in before a first visit.
New Patient Intake (Quick)
Short acupuncture intake — chief complaint, history, lifestyle, and goals.
Pediatric Intake, Ages 0–12 (Quick)
Short intake for a child patient — birth history, development, and current health.
New Patient Intake (Comprehensive)
Comprehensive first-visit intake for an acupuncture practice: contact details, main complaints, body-system symptoms, medical and family history, women's and men's health, and diet.
Pediatric Health History, Ages 0–12 (Comprehensive)
Health history for a child patient: family, pregnancy and birth, development, feeding, sleep, digestion and past conditions.
Form template questions, answered.
Are these forms free to use?
You can preview every template and read what it asks without an account. To use one as your own form, add it to Goji, where you get an editable copy you can share by link or embed on your website.
Are these templates legally or medically sufficient?
They are general starting points, not legal, medical, or compliance advice. Requirements differ by state, country, and profession, so have an attorney or your licensing board or association review anything you use.
Can I edit a template after I add it?
Yes. You get your own copy in the form builder and can reword, reorder, add, or remove questions. Your changes never affect the template or anyone else's copy.
Do patients need an account to fill these out?
No. A form is a plain link, or an embed on your own site, that opens on any phone or computer.
Templates, not advice
These templates are general starting points, not legal, medical, or compliance advice. Review and adapt every template for your practice, and check the requirements in your state or country and for your profession with a qualified professional, such as an attorney or your licensing board or association, before you use it. Goji doesn't guarantee that a template meets any law or standard.