Parago Jones Acupuncture
Parago Jones, L.Ac., DipI. Ac.
Denver Office: 1441 York St., Ste 214
Denver, CO 80206
Phone: 720-328-2981
Welcome to my office,
Dear New Client,
I have found it extremely helpful to have you prepare some information before your first appointment to insure
that the visit is as thorough and useful as possible. These forms are statements of disclosure, waiver, and a
medical history intake. Please read and complete all the pages enclosed. Thank you for putting your time into
this preparation. Please remember to bring these completed forms to your initial session.
Additionally, please wear only loose clothing so to facilitate the treatment more easily. Do not wear perfume or
cologne. Please do not wear any sportswear undergarments. Arriving five minutes early for your appointment
is ideal so to enter the treatment calm and relaxed.
I look forward to meeting you.
Sincerely,
Parago J.D. Jones
Cancellation Policy: *If you need to cancel or re-schedule this appointment or any follow-up
appointments, please call 24 hours in advance at the appropriate office number. On the first
appointment not cancelled 24 hours beforehand you will be given a courtesy waiver of fees. The second
time will require a 50% reimbursement for the missed appointment. All appointments thereafter that are
not cancelled or rescheduled 24 hours beforehand will be charged the full appointment fee.
Parago Jones Acupuncture
Parago Jones, L.Ac., DipI. Ac.
Denver Office: 1441 York St., Denver, CO 80206 Phone: 720-232-8012
Longmont Office: 614 Baker St., Longmont, CO Phone: 720-232-8012
Patient History
Please answer as completely as possible.
Name __________________________________________________________ Date _____________________
Age ______ DOB __________ Sex _______ Marital Status __________ Height _______ Weight _________
Referred by? ______________________________________________________________________________
Main Reason for Visit? ______________________________________________________________________
Known Diagnoses or Health Problems: __________________________________________________________
__________________________________________________________________________________________
Personal Health Goals: _______________________________________________________________________
Other Practitioners Involved in Your Case: List profession. I.E. Western MD, Naturopath, Chiropractor,
Acupuncturist, Other: _______________________________________________________________________
Rate your current level of health: (Circle) (very poor) 1 2 3 4 5 6 7 8 9 10 (excellent)
Rate your current level of energy: (Circle) (very poor) 1 2 3 4 5 6 7 8 9 10 (excellent)
List All Medications currently taking: ___________________________________________________________
__________________________________________________________________________________________
List all Supplements currently taking: ___________________________________________________________
__________________________________________________________________________________________
Allergies: (List all if any) ______________________________________________________________________
Operations/Surgeries/Accidents/Serious Illnesses/HIV positive/Hep B/Hep C positive: ____________________
__________________________________________________________________________________________
Health Habits: Smoke? Circle – Yes – No How many per day if yes? ______________ Coffee: Circle – Yes – No
If yes how much per day? __________________ Soft Drinks? Circle – Yes – No If yes, how many per day?
___________ Glasses of water per day? Yes – No How many fluid ounces per day? ____________________
Do you exercise? If so how often / what? ________________________________________________________
Number of courses of antibiotics: Less than 5 ______ 5-10 ______ 10+______ Courses of steroids ______
(2)
Write P for “past, C for “current”
Stools & Urine:
Energy Level
_____ Are you fatigued, or do you fatigue easily?
______ Do you generally feel cold?
______ Do you have cold feet or hands?
______ Do you ever have low grade fever?
______ Do your hands and cheeks warm up easily?
______ Do you wake up sweating during the night?
Thirst & Dryness:
______ Do you have dry eyes?
______ Do you have dry nose or lips?
______ Do you have dry skin or dry hair?
Sleep:
______ Do you suffer from insomnia?
______ Do you go to sleep easily but wake in the night and
have difficulty falling back to sleep?
______ Do you have difficulty falling asleep but once asleep
can stay asleep?
______ Do you have restless sleep?
______ Do you have uncomfortable dreams?
Are your stools?
______ Normal? (1 – 2x per day with same shape/size)
______ Loose? Often? _________ Sometimes? _________
______ Hard/Dry?
______ Constipated?
______ Erratic (Sometimes loose, sometimes formed)?
______ Bowel movements less than 1x day?
______ Is there blood or mucous in your stools?
______ Do you experience urgency to defecate?
______ Do you have hemorrhoids?
______ Do you have a prolapsed rectum?
______ Is your urine proportionate intake to output?
______ Is your urine unusually scanty and dark?
______ Is your urine unusually profuse and clear?
______ Do you wake more than once at night to urinate?
______ Do you experience any dribbling of urine?
______ Do you have an urgency to urinate?
______ Do you experience burning with urination?
______ Do you have a prolapsed bladder?
______ Kidney stones?
______ Kidney infections?
Pain: (mild) 1 2 3 4 5 6 7 8 9 10 (severe) (Circle)
Emotions:
Do you experience frequent:
______ Anger
______ Fear
______ Worry
______ Sadness
______ Depression
______ Anxiety
______ Irritability
______ Do you experience mood swings?
______ Are they related to eating and not eating?
______ Do you take mood regulating prescription medications?
______ Have you been diagnosed as bi-polar?
Left (Lt) – Center (Ct) – Right (Rt)
______ Neck: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
______ Shoulders: 1 2 3 4 5 6 7 8 9 10 - [ Lt – Rt ]
______ Arms/Elbows: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt ]
______ Hands/Wrists: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt ]
______ Mid-Back/Chest: 1 2 3 4 5 6 7 8 10 -[ Lt – Ct – Rt ]
______ Low Back: 1 2 3 4 5
______ Slipped Disc
______ Bulging disc
______ Fused disc
6 7 8 9 10 – [ Lt – Ct – Rt ]
______ Sacra-iliac pain
______ Ruptured disc
______ Coccyx pain/issues
______ Hips: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
Appetite & Taste:
______ Has your appetite altered recently?
______ Do you have a poor appetite?
______ Do you have poor digestion?
______ Bloating in stomach after eating
______ Bloating or gas in lower abdomen
______ Burping frequently after eating
______ Tiredness after meals
______ Legs: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
______ Knees: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
______ Ankles: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
______ Feet: 1 2 3 4 5 6 7 8 9 10 – [ Lt – Rt – Ct ]
Comments: ___________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
(3)
Indicate C for “current” or P for “past”
General:
______ Fever, chills, sweats
______ Night sweats
______ Nervousness/anxiety
______ Irritability
______ Generally feel run down
______ Loss of weight
Skin:
_____ Non-healing sores
_____ Hives, rash
_____ Eczema, psoriasis
_____ Frequent infection or boils
_____ Abnormal pigmentations, moles
_____ Warts
_____ Herpes:
_____ lips
_____ genital
_____ zoster (shingles)
_____ Skin cancer or melanoma
_____ Brittle or weak nails
_____ Infected nails
_____ Peeling, itchy feet
_____ Thickened toe nails/yellow
Cardiovascular:
_____ High blood pressure
_____ Palpitations, irregular heart beat
_____ Rheumatic fever
_____ Chest pain or angina
_____ Shortness of breath with walking
_____ Shortness of breath lying down
_____ Difficulty walking two blocks
_____ Heart trouble
_____ Heart attack
_____ Heart murmur
_____ Swelling of hands, feet, or ankles
_____ Pain in calves with walking, relieved by rest
_____ Varicose veins
Mental Emotional/Neurologic
______ Fainting spells
______ Epilepsy/Seizures
______ Stroke or mini-stroke
______ Paralysis
______ Weakness of an arm or leg
Endocrine:
_____ Diabetes
_____ Thyroid disease
_____ Heat or cold intolerance
_____ Change in hair growth or texture
_____ Excessive thirst or urination
_____ Sexual problems
_____ Hormone therapy
_____ Low or high sex drive
_____ Radiation to neck or face area
_____ Low blood sugar
Head-Eyes-Ears-Nose-Throat
_____ Headache
_____ sinus
_____ tension
_____ migraine
_____ Head feels “heavy”
_____ Loss of memory
_____ Light-headedness or spaciness
_____ Light bothers eyes
_____ Eye disease or injury
_____ Blurry vision
_____ Double vision
_____ Glaucoma, cataracts
_____ Loss of balance
_____ Dizziness or vertigo
_____ Loss of hearing
_____ Ear disease
_____ Impaired hearing
_____ Ringing/buzzing in ears
_____ Ear pain
_____ Discharge from ear
_____ Runny nose or nasal discharge
_____ Nosebleeds
_____ Loss of taste
_____ Sores in mouth
_____ Sore tongue
_____ Chronic sinus trouble
_____ Snoring
_____ Sore throats
_____ Tooth & gum problems
Hematologic:
_____ Anemia
_____ Phlebitis/blood clots in veins
_____ Are you slow to heal after cuts or bruising
_____ Difficulty with bleeding excessively after
tooth extraction or surgery
_____ Mononucleosis
Locomotor-Musculoskeletal:
_____ Joint swelling
_____ Arthritis or joint pain
_____ Weakness of muscles or joints
_____ Difficulty walking
_____ Leg cramps
_____ Leg ulcers
Respiratory:
_____ Frequent colds
_____ Difficulty breathing
_____ Chronic or frequent cough
_____ Asthma or wheezing
_____ Emphysema
_____ Spitting up blood
_____ Pleurisy (pain when breathing)
_____ Pneumonia
_____ Coughing up sputum
Gastrointestinal:
_____ Heart burn/indigestion
_____ Food sticks in throat
_____ Difficulty swallowing
_____ Vomiting blood or food
_____ Ulcer (Stomach or duodenal)
_____ Gallbladder disease or stones
_____ Liver trouble/hepatitis
_____ “Nervous” stomach
_____ Nausea and/or vomiting
_____ Thin or ribbon like stools
_____ Hard or difficulty bowel movements
_____ Bloody or black stools
_____ Painful bowel movements
Male (only):
______ Testicular pain/swelling
______ Urinary frequency
______ Difficulty in starting stream of urine
______ Discharge from penis
______ Frequent night urination
______ Prostrate pain/swelling
______ Undescended testicle
______ Impotence
Female (only):
______ Last menstrual period
______ Currently pregnant?
______ Age periods started
______ Duration of periods ______ days
______ Frequency of periods, every ______ days
______ Pelvic pain or infection
______ Excess discharge
______ PMS
______ Menstrual cramping
______ Irregular cycle
______ Number of pregnancies
______ Number of miscarriages
______ Number of abortions
______ Uterine fibroids
______ Hysterectomy
______ Date of menopause
______ Hot flashes
______ Menopausal bleeding
______ Nipple discharge or bleeding
______ Abnormal PAP smear
______ Prolapse uterus
Comments: _________________________________
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