CCM Health Services: Initial Clinical Intake & Diagnostic Formula
Welcome to your holistic health journey. Traditional Chinese Medicine views the body as an interconnected ecosystem. By looking at your physical patterns, energetic channels, and lifestyle rhythms, we can treat the root cause of your symptoms, not just the surface issues. Please complete this clinical formula with absolute accuracy.
1. Patient Identification
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Email Address:
*
example@example.com
Phone Number:
Format: (000) 000-0000.
2. Primary Clinical Focus
What is your primary chief complaint or health concern today? (Please describe symptoms, pain levels, and duration).
*
What are your secondary health or wellness goals?
*
3. Modality Preferences & Familiarity
Have you ever received Acupuncture or TCM treatments before?
*
Yes
No
Which modalities are you open to or specifically seeking? (Select all that apply):
*
Acupuncture: Fine needle insertion to regulate Qi and blood flow.
Auriculotherapy: Ear acupuncture/seeds for stress, addiction, pain, or nervous system regulation.
Tui Na: Chinese therapeutic bodywork and meridian massage.
Moxibustion (Moxa): Thermal therapy using mugwort herb to warm channels and dispel cold.
Cupping Therapy: Suction therapy to relieve deep myofascial tension and promote circulation.
4. Systems Review (The TCM Meridian & Diagnostic Data)
Please select any symptoms you experience regularly:
Please select any symptoms you experience regularly:
Rows
Symptoms I Indicators (Check all that apply)
Energy & Sleep
Temperature I Moisture
Back
Next
Rows
Symptoms I Indicators (Check all that apply)
Digestion & Qi
Pain & Musculoskeletal
Nervous System
5. Critical Medical Safety Screeners(Contraindications Check)
The following data is vital to ensure your safety during specific therapies like Acupuncture, Moxa, or Cupping.
1. Are you, or is there a possibility that you might be, pregnant?
*
Yes
No
Not Applicable
2. Do you wear a cardiac pacemaker or any electrical medical implants?
*
Yes
No
3. Do you have a known bleeding disorder, or are you currently taking blood thinners (e.g., Warfarin, Aspirin)?
*
Yes
No
4. Do you experience lymphedema, local skin infections, open wounds, or severe skin conditions? (Crucial for Cupping/Moxa safety)
*
6. Informed Consent & Clinical Disclaimer
Please review and check the box to submit.
*
I hereby consent and agree:
I understand that Classical Chinese Medicine (CCM) and TCM modalities (including Acupuncture, Auriculotherapy, Tui Na, Moxa, and Cupping) are safe, holistic therapies, but may carry minor risks such as temporary bruising (common with cupping), slight soreness, or minor bleeding at the needle site. I certify that the medical history provided above is accurate to the best of my knowledge. I understand that I can request modifications or stop treatment at any time during my session.
[Submit CCM Consultation Request]
Implementation Tips for the TCM Button:
Pulse and Tongue Diagnosis Note:
At the top or bottom of the form, you can add a small note letting them know: "Please note: Your initial session will include a physical examination of your pulse and tongue, which are vital diagnostic tools in Classical Chinese Medicine."
Hipaa / GDPR Data Rules:
Because this form collects explicit medical diagnoses, contraindications (pacemakers, pregnancy, bleeding disorders), your web platform must be secure. Platforms like Jotform (HIPAA-compliant tier), PracSuite, or Jane App are highly recommended for clinical intake buttons rather than generic website contact forms.
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