Intake form template
New Patient Intake (Quick)
Short acupuncture intake — chief complaint, history, lifestyle, and goals.
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
- Covers the basics a first visit needs: the main complaint, relevant history, lifestyle, contact and emergency contact.
- Add questions specific to your style of practice, and remove anything you would not use at a first visit.
What it asks
23 questions across 12 short screens, shown one screen at a time so it works on a phone.
See every question
- 1. First name · Last name · Preferred name
- 2. What brings you in today?
- 3. How long have you had this issue? · How often does it occur?
- 4. What makes it better or worse?
- 5. Have you had acupuncture before? · Any concerns or fears about needles?
- 6. Current medications · Allergies
- 7. Past medical conditions or surgeries · Do you currently smoke?
- 8. How would you describe your sleep? · How would you describe your stress level?
- 9. Phone number · Email · Preferred contact method
- 10. Emergency contact name · Emergency contact phone · Emergency contact relationship
- 11. How did you hear about us?
- 12. What's your main goal for treatment?
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.