Build an Acupuncture Intake Form Read Before the First Needle
Build an acupuncture intake form that records each patient's pain, sleep, and digestion in a database you own.
Build an acupuncture intake form for my clinic that asks about sleep and digestion and flags any pacemaker.
Trusted by Builders Worldwide
Active Builders Worldwide
Apps Successfully Created
Countries Globally Reached
What the Practitioner Reads Before Needling
An acupuncture intake form built in Emergent collects the answers that shape the first treatment plan.
Questions on sleep, digestion, and heat
Ask how the patient sleeps, how meals sit afterward, and whether they tend to feel hot or cold. Each answer gets its own field, so the pattern is readable at a glance.
A body map for where it hurts
Patients tap each sore spot on a front and back figure and score it from 0 to 10. The marks appear on the practitioner's chart beside the main complaint they typed in.
A chart label when e-stim is ruled out
A yes to the pacemaker question puts a No e-stim label at the top of the patient's chart. The practitioner sees it while planning the first treatment, not halfway through.
Medications and supplements, one per row
Patients list each medicine and supplement, herbs included, on its own row with the dose. The practitioner reads a clean list instead of a paragraph typed in a hurry at the door.
Consent signed before the first needle
End with the clinic's consent statement and ask for a typed or drawn signature. The signature is stored with its date and the intake it belongs to, in a database you own.
Source code a developer can take over
Export the code for the form and its chart screens to your GitHub repository on paid plans. A developer can host it on your own servers or keep building on it from there.
How Four Clinics Use the Answers
Six out of 10 for back pain, logged from the tablet
Dovetail Community Acupuncture seats new patients in a shared room of recliners, and each one fills the intake on a tablet by the door. Aurelio Kestner marks low back pain and scores it 6 out of 10. He takes Recliner 4, and Wenqi Lattimore sees his complaint and score on her list before she walks over.
window.awbMockup = { communityClinics: "My community acupuncture clinic treats new patients in one shared room of recliners. Build an intake form that runs on a tablet by the door and asks for the main complaint, a pain score from 0 to 10, and the recliner number. Put each new patient's complaint and score on the practitioner's list as soon as they submit.", electroacupuncture: "My clinic uses electroacupuncture for knee and back pain. Build an intake form that asks every new patient whether they have a pacemaker. When the answer is yes, show a No e-stim label at the top of that patient's chart so the practitioner sees it while planning the first treatment.", herbalMedicine: "I write herbal formulas as well as doing acupuncture. Build an intake form where patients list every prescription medication, herb, and supplement they take, one per row, with the dose. Show me the full list on the patient's chart, and let me add a note to any row I want to ask about at the first visit.", returningPatients: "Returning patients at my acupuncture clinic should answer one question each time they check in: how much the main complaint hurts today, from 0 to 10. Save every score with the visit number, and show the practitioner a bar chart of all past scores on the chart before the next visit." };
No e-stim for any patient who has a pacemaker
Every new patient at Tarrowby Acupuncture answers a pacemaker question, because the clinic uses electroacupuncture for knee and back pain. Efua Asamoah answers yes before her 10:30 visit. Her chart opens with a No e-stim label, and Ruairi Bale plans a manual-needle treatment for her knee.
Two medications and three supplements, one row each
Sebastian Pruett takes 2 prescription medications and 3 supplements, and the Stillbrook Herbs and Acupuncture intake gives each one a separate row and a dose field. Yumiko Lisle reads all 5 rows before she writes his herbal formula. Any row she wants to ask about gets a note for his first visit.
Four neck pain scores line up into one chart
Leopold Strand answers one question each time he checks in at Kittering Acupuncture: how much his neck hurts today, from 0 to 10. He scored 7 at visit 1 and 3 at visit 4. Before visit 5, Thessaly Haldane opens his chart and sees all four scores as bars.
How to Create an Acupuncture Intake Form
Seven steps to create an acupuncture intake form that puts the answers a treatment depends on in front of the practitioner.
List every answer that would change what happens in the first session: the main complaint, a pacemaker, pregnancy, current medications, and how the patient sleeps and digests. A question whose answer changes nothing about the treatment can come off the form.
Open with the main complaint and a 0 to 10 pain score, right after contact details. Add a body map with front and back views. A patient taps the sore spot instead of describing it in a text box.
Ask about sleep, digestion, appetite, and whether the patient runs hot or cold, in everyday words. Offer checkboxes such as wakes at night or bloating after meals, and leave one open field for anything the list misses.
Collect every prescription and supplement, herbs included, as a separate entry with its dose and how often it is taken. Ask about a pacemaker as a standalone yes or no question, which lets that one answer set a label on the chart.
Put the questions and the chart labels into one prompt, along with who should see each answer. Emergent builds the acupuncture intake form, the patient database behind it, and a chart screen for practitioners. Ask for changes in plain English later.
Close the form with your consent statement and cancellation terms, followed by a typed or drawn signature. Keep the wording short enough to read on a phone, and keep a copy of each version so you know which one a patient signed.
Fill in the form on a phone as a made-up patient with a pacemaker and two supplements. Check that the No e-stim label shows on the chart, that both supplements arrive as separate entries, and that the pain score lands in the database.
Why Build Acupuncture Intake With Emergent?
A clipboard packet gets read with the patient already on the table. An online intake is on the chart before the visit starts.
|
Jotform | Google Forms | Typeform | |
|---|---|---|---|---|
| How you build | Describe it in plain English | Templates, editor, AI generator | Editor, with Gemini drafting on some Workspace plans | Templates, editor, AI assist |
| Where responses live | A database table you own, plus any integration | Jotform account | Google Sheets | Typeform account |
| Response limits | No response caps | Monthly submission caps by plan; the form stops at the cap | No limit | Monthly response caps by plan; the form closes at the cap |
| Code ownership | Full code export to GitHub on paid plans | None | None | None |
Pick the Pricing Plan That Works for You
Choose the plan that fits your building ambitions. From weekend projects to enterprise applications, we've got you covered.
Find the right form
for whatever you're collecting
Frequently Asked Questions
Your Questions, Answered
Don't change this element unless you know what you are doing
More things you can build
with Emergent
on Emergent today
