Intake form template
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.
A starting point, not legal or medical advice. Read the full note
This is the form your patients would see. It’s a preview: nothing you enter is saved.
About this template
- A thorough first-visit history: main complaints, symptoms by body system, personal and family history, women's and men's health, and diet.
- It's long. Ask patients to complete it before their visit rather than in the waiting room, or start from the quick version.
- Some paper-form features (symptom severity ratings, a family-history grid, a body diagram) are simplified into checklists and free text here.
What it asks
82 questions across 35 short screens, shown one screen at a time so it works on a phone.
See every question
- 1. First name · Last name · Date of birth
- 2. Gender · Marital status
- 3. Street address · City · State · Zip code
- 4. Daytime phone · Daytime phone type · Alternate phone · Alternate phone type · Email
- 5. Place of employment · Occupation
- 6. Emergency contact phone · Emergency contact alternate phone · Insurance coverage · Health insurance company
- 7. How did you hear about us? · Who or what referred you?
- 8. Main complaint · How long have you had it? · How often does it occur?
- 9. What caused it? · What is the worst it can be?
- 10. What treatments have you tried? · Do treatments give temporary relief? · Do treatments fix the problem? · Do treatments cause side effects?
- 11. How does this affect your life? · How does it affect your family and your sleep? · How does it affect your work and your hobbies?
- 12. What is your goal or plan if the problem continues 5, 10 or 20 years?
- 13. Second complaint · Other complaints
- 14. How committed are you to getting rid of the problem(s), from 1 to 10? · Have you had acupuncture before? · If so, where and with whom? · Do you have any concerns or fears about needles? · What are your concerns?
- 15. What are your goals for your acupuncture visits?
- 16. Medical conditions and surgeries · Allergies
- 17. Prescription medications · Supplements
- 18. Liver / gallbladder symptoms
- 19. Heart / small intestine symptoms
- 20. Spleen / stomach symptoms
- 21. Lung / large intestine symptoms
- 22. Kidney / bladder symptoms
- 23. Which symptoms bother you most, and how severe are they?
- 24. Health problems you have or have had
- 25. Health problems in your family · Family members who have died
- 26. Muscle and joint problems · Where are these problems? · How would you describe the pain?
- 27. Hysterectomy: were the ovaries removed? · Could you be pregnant now? · Post-menopausal bleeding?
- 28. Number of pregnancies · Number of births · Number of miscarriages · Number of abortions
- 29. When did your last period end? · How many days is your monthly cycle? · How many days does bleeding last?
- 30. Describe your menstrual flow · Color of menstrual flow · Birth control
- 31. Cramping · Clotting
- 32. Other women's health issues · Premenstrual symptoms
- 33. Men's health issues
- 34. What do you eat and drink in a typical week, and how much? · Do you get about 50g of protein a day?
- 35. Do you eat breakfast? · Do you often eat fast food or on the run? · Anything else you'd like us to know?
How to use it
- Add it to Goji. You get your own editable copy.
- Reword or remove anything that doesn’t fit your practice, and have the wording reviewed where it matters.
- Send patients the public link, or embed the form on your own website.
- Answers arrive in your submissions inbox, ready to become a patient record.
Questions about this intake form template.
Do patients need an account to fill this out?
No. Once you add it to Goji, the form gets a plain public link that opens on any phone or computer with no account, password, or app. You can also embed it on your own website.
Can I change the questions?
Yes. Adding a template creates your own copy in the form builder, where you can reword, reorder, add, or remove any question before you share it. Changing your copy never changes the template.
Is this template legal or medical advice?
No. It is a general starting point. Check what your state or country and your profession require, ideally with an attorney or your licensing board or association, before you use it with patients.
A template, 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.