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Alternative Medicine Patient Intake Form Template

Streamline Your Patient Onboarding with This Efficient Form

Gathering accurate patient information in alternative medicine is crucial for effective treatment. This patient intake form template is designed to help practitioners like you efficiently collect essential data, ensuring a smooth onboarding process. With clear sections for health history, current medications, and treatment goals, this form facilitates better communication with your clients, saves time on paperwork, and improves patient satisfaction-all while maintaining compliance with WCAG-aligned standards. Experience the ease of using this live template to enhance your practice.

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your gender, please specify (optional)
Email
Phone
Preferred contact method
Phone
Email
Text message
Any
Address
Emergency contact name
Emergency contact phone
Emergency contact relationship
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Reason for visit today
How did you hear about us?
Referral
Online search
Social media
Event
Walk-in
Prefer not to say
Other
Please Specify:
Which complementary or alternative modalities have you tried before?
Please Specify:
I consent to assessment and treatment
Yes
No
Typed signature (enter full legal name)
Signature date
I acknowledge receipt of the privacy practices notice
Yes
No
Are you currently under the care of a physician for any condition?
Yes
No
Current diagnoses (select all that apply)
Please Specify:
If other diagnoses, please specify
Surgical history and hospitalizations (with dates, if known)
Family history of major conditions (select all that apply)
Please Specify:
Are you currently pregnant or planning pregnancy?
Currently pregnant
Planning pregnancy
Not pregnant
Not applicable
Prefer not to say
Current prescription medications (name, dose, frequency)
Over-the-counter medicines and supplements (name, dose, frequency)
Allergy details (substances and reactions)
Known allergies or sensitivities
No known allergies
Medications
Foods
Environmental
Latex
Other
Please Specify:
Main areas of concern (select all that apply)
Please Specify:
Pain level right now
No pain
Mild
Moderate
Severe
Very severe
Where is your pain or discomfort?
How often do your symptoms affect daily activities?
Never
Rarely
Sometimes
Often
Always
Sleep quality in the past 2 weeks
Poor
Below average
Average
Good
Exceptional
How often do you feel stressed?
Very rarely
Rarely
Sometimes
Often
Very often
Satisfaction with your energy level
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Physical activity in a typical week
None
1-2 days
3-4 days
5-7 days
Prefer not to say
Tobacco use
Never
Former
Occasional
Daily
Prefer not to say
Alcohol use
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
Prefer not to say
Dietary preferences or restrictions
Please Specify:
Do you have any implanted devices?
None
Pacemaker
Insulin pump
Neurostimulator
Metal implants
Prefer not to say
Other
Please Specify:
Do you have a bleeding disorder or are you taking blood thinners?
Yes
No
Areas to avoid during treatment
Do you have allergies to adhesives or oils?
Yes
No
What are your treatment goals?
Treatment preferences (select all that apply)
Please Specify:
Accessibility accommodations needed
Preferred appointment times
Morning
Afternoon
Evening
Weekdays
Weekends
No preference
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Paper art illustration depicting an alternative medicine patient intake form for FormCreatorAI article

When to use this form

This intake form is ideal for integrative, naturopathic, acupuncture, chiropractic, and functional medicine clinics onboarding new patients or moving off paper. Use it before the first consult to capture symptoms, whole-person history, supplements, allergies, and lifestyle so you can build a targeted plan on day one. It helps you triage complex cases, flag contraindications, and cut rooming time. Pair it with a New patient registration form to collect insurance and consent, the Patient demographic information form for contact details, and the Medical information form for medications and past diagnoses. If you offer telehealth, send it right after scheduling so providers can review answers and prep labs or a coaching roadmap.

Must Ask Alternative Medicine-Patient Intake Questions

  1. What are your top three health goals and the symptoms you want to address first?

    This focuses the visit and sets measurable outcomes, so you can prioritize care. Clear goals also help track progress and decide when to adjust the plan.

  2. Which diagnoses, medications, and supplements are you currently taking (include doses and start dates)?

    Full lists reduce adverse interactions and duplications. Recent start dates reveal trigger patterns and guide safe changes.

  3. Do you have any allergies or sensitivities to medications, foods, or environmental triggers?

    Allergy details prevent reactions and shape testing and diet choices. Noting severity and past reactions helps you set precautions.

  4. Describe your typical diet, sleep, stress, movement, and substance use over the past 30 days.

    Lifestyle context uncovers root causes and realistic levers for change. You can compare these answers with findings from a Health examination form to build a precise plan.

  5. Which therapies or lifestyle changes have you tried before, and what helped or made things worse?

    Prior results save time and avoid repeating ineffective care. You learn patient preferences, which improves adherence and rapport.

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