Acupuncture Session Feedback Form

Acupuncture Session Feedback Form — Form Fields

This feedback template includes 10 fields. Collect patient feedback on acupuncture treatment effectiveness, practitioner skill, and clinic environment. Free to customize and use on ZenBuild.

• Your Name (text, optional)
• Email Address (email, optional)
• Visit Number (dropdown selection, required) — options: First Visit, 2nd-3rd Visit, 4-6 Visits, 7+ Visits
• Primary Reason for Treatment (dropdown selection, required) — options: Pain Relief, Stress/Anxiety, Sleep Issues, Digestive Health, Fertility, General Wellness, Other
• Treatment Effectiveness (rating, required)
• Practitioner Skill and Attentiveness (rating, required)
• Clinic Environment and Comfort (rating, required)
• Overall Satisfaction (rating, required)
• Have you noticed improvement in your condition? (multiple choice, required) — options: Significant, Some, Minimal, Not Yet
• Comments or Questions for Your Practitioner (long text, optional)