Please take a moment to provide us with some information about yourself and
your health conditions so that we may do our best to treat you.

Bliss Acupuncture Clinic considers this information privileged physician/patient communication and will hold it in confidence.

Leave blank for fields that do not apply to you.

*Your Email

*Full Name

*Date of Birth




Marital Status

*Street Address



*Zip Code

*Phone Number

Cell Phone Number


Business Address



Zip Code

How did you hear about Bliss Acupuncture Clinic?

Have you previously been treated with acupuncture or oriental medicine?

Emergency Contact Information



Phone Number

Chief Complaint / Major Health Concern

How did this condition develop?

How long has this condition persisted?

Is there anything that makes it better?

Is there anything that makes it worse?

Have you ever been treated for this condition?

If yes, when?


By whom?

What was the diagnosis?

What kind of treatments?

What was the result of the treatments?

Family Medical History

Maternal side

Paternal side


Birth History

Childhood Health

Geographic location of upbringing

Current emotional health

Current quality of life, relationship quality

Current predominant emotion

Recently, have you had any unusual stress

Stress level

Hobbies / Recreational habits

Do you have a regular exercise program?

If yes, describe

Traveled abroad in the past year

If yes, where

Do you use coffee/tea, tobacco, or alcohol?

If yes, how much of each and for how long?

Please list any substances that you are allergic to

Medications, herbs, vitamins, and supplements that you are currently taking

Please list any major surgeries you have had & date

Please list any significant traumas

Do you have, or have you ever had any infectious disease?

If yes, please describe

Please check all significant illnesses that apply

Please check any symptoms you currently have or have experienced in the past 3 months.

General Symptoms

Head, Ear, Eyes, Nose & Throat Symptoms

Respiratory Symptoms

Cardiovascular Symptoms

Gastrointestinal Symptoms

Muscoskeletal Symptoms

Check if you are or have experienced any pain, numbness, or weakness in the following

Genitourinary Symptoms

Neurological Symptoms

Dermal/Skin Symptoms

Diet and Lifestyle Symptoms

Emotional Symptoms

Male Symptoms(Only)

Female Symptoms(Only)

Date of Last Pap Smear

Number of Pregnancies

Number of Abortions

Number of Births

Number of Miscarriages

Pregnant, if yes how many months otherwise leave blank

Age of 1st Menses

Time between Menses

Duration of Menses

First date of last Menses