New Patient Health History & Intake Form — Editable Word Template

A thorough new-patient intake built specifically for acupuncture and TCM practices. Goes beyond a generic medical history form — includes a categorized health history checklist (cardiovascular, bleeding/clotting, pacemakers, skin conditions, and more) relevant to needle placement and modality selection, plus a Traditional Chinese Medicine review of systems and an "office use only" section for your tongue/pulse notes and working diagnosis.

Includes: patient info, reason for visit, categorized health history, medications/allergies, surgical history, lifestyle, pregnancy screening, TCM review of systems, signature, and practitioner notes section.

Format: Microsoft Word (.docx), 6 pages, fully editable.