Lotus Path Wellness Center www.lotuspathwellness.com

813-964-0847 info@lotuspathwellness.com

Thank you for selecting Lotus Path Wellness Center as your care provider. I offer optimum health naturally through Oriental and Functional Medicine practices. Your first session with me will last an hour and a half. Since a full 90 minutes is set aside for you, please advise us as soon as possible if you find that you are not able to keep the appointment. Additional appointments take 30 –60 minutes, based on your needs. Please print the forms below that need to be completed. Some forms are straightforward and some may require that you think about the answers. We find that many of our patients are amazed at how quickly their situation changes for the better, and sometimes it is good to be reminded of how you felt before you started your path to optimal wellness. Please bring these completed forms to your first appointment: 1. Patient Registration Form/Personal History

5. Metabolic Assessment Form Key

2. Patient Informed Consent 6. Supplements and Pharmaceuticals List

3. Agreement to Abide by Office Policies 7. Seven Day Diet Log 4. Patient History If you are taking a multi-nutrient supplement, include the amount of each individual nutrient contained in each capsule. If it is easier, simply bring the bottles in with you at the time of your visit. Also, if you have had recent lab reports or medical records that are pertinent to your current situation, please bring copies of those with you. I will act as a coach/consultant in your healthcare, offering alternatives that conventional medicine may not consider. Should you have any questions, please call us at 964-0847. We request that you honor the 24-hour cancellation policy as a courtesy to those waiting for an appointment. If 24 hours' notice isn't given, you will be charged $50. We look forward to working with you. Sincerely, Dr. Maria Belluccio Lotus Path Wellness Center

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Patient’s Agreement to Abide by OFFICE POLICIES

____________________________________________________________ GENERAL INFORMATION Lotus Path Wellness Center Is by appointment only. Our practice covers a wide variety of medical and health related issues to aid in creating balance and wellness through Oriental and functional medicine.

POLICIES Office visits are made by appointment only. The nature of this practice is to provide you with the best possible care and service so that you acquire optimum health in natural ways. Therefore, you may experience unexpected delays in being seen. Please be assured that you will be attended to as promptly as possible and be given the same careful attention as those who came before you. Full payment is expected at the time of service. You may pay with credit card, debit card, check, or cash. We accept Visa, MasterCard, and Discover only. A 24-hour notice is required for cancellation; otherwise you WILL BE billed a $50 fee for the appointment time. Nutritional supplements may be offered to patients based on their individual needs. Supplements, once opened, cannot be returned. I have read and understand the above office policies, and I agree to them as a condition for being seen by Dr. Maria Belluccio. ________________________________________________________ Date_______________________________

Patient (or Guardian) Signature

PATIENTREGISTRATIONFORMTomypatients:theinformationcollectedisconfidentialandwillhelpmedetermineifthetreatmentofferedherewillhelpyou.IfIdonotsincerelybelievethatyourconditionwillrespondsatisfactorily,Iwillnotacceptyourcase.InorderthatIunderstandyourconditionproperly,pleasebeasaccurateandlegibleaspossiblewithcompletingtheenclosedforms.NAME___________________________________Gender________MaritalStatus___________DateofBirth_____________________________SSNumber_____________________________Address____________________________________City_______________State____Zip______

HomePhone___________________Cellphone__________________Other________________Emailaddress___________________________________________________________________Employer______________________________________Occupation______________________BusinessAddress________________________________Bus.Phone_______________________FamilyPhysician________________________________Phone#_________________________Emergencycontact____________________________Relationship_______________________Phone#______________________________________________________________________

Whoreferredyoutomypractice?__________________________________________________

I, _________________________________________________, hereby request and consent to the performance of acupuncture and related modalities on me (or on the patient listed below for whom I am legally responsible) administered by the acupuncture physician listed below and/or other licensed acupuncturists who now or in the future may treat me while employed by, working or associated with, or serving as back-up for the acupuncture physician named hereunder, whether the treatment is performed at the clinic whchi may be listed below or at some other location.

I understand that the methods of treatment may include, but are not limited to acupuncture, electro-acupuncture, moxibustion, vasopneumatic cupping, electro-therapy, Tui-na (oriental massage), western massage, applied kinesiology and natural internal medicines, which may include herbs, minerals, animal by-product, homeopathic dilutions and nutritional supplements, which may be administered for oral consumption or topical application and may be in the form of teas, pills, powders, tinctures or sterile injectable. I understand that certain herbal teas may need to be cooked or otherwise prepared by me according to the instructions provided by the acupuncture physician. I also understand that certain teas may have an unpleasant smell or taste. I understand that it is my responsibility to notify a member of the clinical staff of any unanticipated or disturbing effects associated with the consumptions of these medicines. I understand that it is my responsibility to inform my physician of any and all other medications that I am taking so that any untoward interactions can be avoided. Although negative interactions are rare, I do understand that the correct medial knowledge concerning interactions of prescription pharmaceuticals with herbs and other natural supplements is incomplete.

I have been informed that acupuncture and its related modalities is a safe method of treatment with few and infrequent side effects. The side effects may include bruising, temporary numbness or tingling near the needle sites, temporary lightheadedness which may last for an hour or more, or fainting due to “needle shock”. Significant bruising is a common side effect of cupping and scraping modalities. Burns and/or scarring are unlikely potential risks of moxibustion treatment. Rare and unusual risks of acupuncture treatment include spontaneous miscarriage, nerve damage, organ injury and pneumothorax. Infection is another rare, yet possible risk of acupuncture. My practice complies with the highest industry standards and legal requirements by using only pre-sterilized disposable needles and maintaining a clean and safe working environment. I understand that this document describes only the known major risks and possible side effects of acupuncture and related treatments. The herbs and other nutritional supplements that are used in my practice are considered safe but may be toxic if consumed in large doses. Some supplements may be contraindicated during pregnancy. I understand that I must carefully follow the acupuncture physician’s instructions regarding dosage and other usage parameters. I further understand that I must inform my acupuncture physician if I am or if I become pregnant.

I understand that positive results of treatment are not guaranteed. I understand that all my medical records will be kept confidential and will not be copied or view by others without my express written consent, except as may be required by legal mandate.

By voluntarily signing this form, I am indicating that I have read (or had read to me) this “Consent to Treatment” and have had the opportunity to ask questions about any concerns. I intend this consent to cover the entire course of treatments for my present condition and for any future conditions for which I might seek treatment from this acupuncture physician.

PATIENT’S NAME: _________________________________________________________ Date: ________________________________________ Please print name.

Patient Signature: ________________________________________________________ Relationship to patient: ______________________________ (or legal representative) MARIA E. BELLUCCIO, R.N, A.P. , D.O.M.

LotusPathWellnessCenter

PATIENTHISTORY

Patient Name: ________________________________ DOB: ___________ Age: ______Gender: M F

T___ Heart Rate_______ Blood Pressure ________ Respiration ______Height _______Weight _______

Allergies_____________________________________________________________________________

Medical Background

What is your chief complaint? ___________________________________________________________

Describe more fully what you experience, include onset, symptoms and their effect on daily activities _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past treatments/tests____________________________________________________________________

What helps?_________________________________ What hinders?____________________________

Practitioners involved in health care _____________________ __________________________

_____________________ __________________________

Pain: Onset: o Rapid o Gradual

Quality: o Dull o Burning o Sharp o Heavy

Location: oJoint o Muscle o Low back o Under ribs o Fixed o Moving o Radiating

Headache: Location o Side o Top o Occipital o Frontal

Frequency o Daily o Weekly x______

Rate the severity of your condition. Circle the box using scale with “10” as unbearable.

1 2 3 4 5 6 7 8 9 10

Your Lifestyle

o Alcohol o Marijuana o Stress o Tobacco o Drugs o Occupational Hazards o Exercise Type: ________________________ Frequency: _____________________

Past Medical History Mark conditions you have had with a “1” and have currently with a “2”

o Accidents o Depression o Low Blood Pressure o Seizures o AIDS/HIV o Diabetes o Lupus o Stroke o Alcoholism o Emphysema o Measles o Thyroid Disease o Allergies o Epilepsy o Multiple Sclerosis o Tuberculosis o Anxiety o Glaucoma o Mumps o Typhoid Fever o Appendicitis o Goiter o Pacemaker o Ulcers o Arteriosclerosis o Gout o Pleurisy o Varicose Veins o Arthritis o Heart Disease o Pneumonia o Venereal Disease o Asthma o Hepatitis o Polio o Whooping Cough o Cancer o Herpes o Prostate Disease o Fibromyalgia o Carpal Tunnel o High Blood Pressure o Rheumatic Fever o Other (specify) o Chicken Pox o Irritable Bowl o Scarlet Fever ________________ __________________ List Surgeries: Major Trauma: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ List Medications, Vitamins, Herbals: Please see Supplements and Pharmaceuticals form Family Medical History o Arteriosclerosis o Cancer o High Blood Pressure o Thyroid Disease o Asthma o Depression o Seizures o Alcoholism o Diabetes o Stroke

Review of Systems Lung Perspiration: o Scant o Profuse o Daytime o Nighttime

o Upper body o Lower Body o Spontaneous o Other_________

Nose: o Stuffy o Dry o Congested o Nosebleeds o Sinus infections o Shortness of breath o Difficulty inhaling o Difficulty exhaling o difficult breathing while lying down o Wheezing

o Sneezing o Frequent colds and flues o Allergies

Emotions: o Recent loss or long term grief o waking 3-5 a.m. o sadness Cough: o Dry o Productive o Hacking o Non Productive Sputum: o Clear o White o Blood tinged o Yellow

o Green o Rusty Amount: o Copious o Scant o Difficulty rising Skin: o Dry o Itchy o Moist o Rashes

o Acne o Body hair loss o Eczema o Psoriasis o Dandruff o Fungal infections Kidney/Urinary Bladder Urine: o Light o Dark o Clear o Cloudy

o Sand and grit o Bloody o Strong order o Sweet order Frequency: o __/day o __/night o Urgency o Hesitancy o Week flow Amount: o Dribble o Intermittent o Intake = Output o Urinary incontinence Pain: o Lower back o Week knees o Cold feet o worse in a.m. o Worse in p.m. Sexual desire: o Low o High o Impotence o Premature Ejaculation Energy: o Lack of stamina o Need lots of sleep Hearing: o Hearing loss o Tinnitus (low humming) o Vertigo o Dizziness Hair: o Loss/thinning o Dry o Premature gray Liver Eyes: o Vision change o Blurred o Night o Red

o Dry o Gritty o Floaters o Itchy o Watery o Painful o Pressure o Vertex Headache o Bitter taste in the mouth

Pain: o Muscle cramps/spasms o Pain in ribs, groin, pelvis o Hesitancy o Week flow

Amount: o Dribble o Intermittent o Intake = Output o Urinary incontinence Pain: o Lower back o Week knees o Cold feet o worse in a.m. o Worse in p.m. Sexual desire: o Low o High o Impotence o Premature Ejaculation Energy: o Lake of stamina o Needs lots of sleep Hearing: o Hearing loss o Tinnitus (low humming) o Vertigo o Dizziness Emotions: o Fear o Disgruntled o Easily defeated o Diminished motivation Hair: o Loss/thinning o Dry o Premature gray Heart o Palpitations o Dizziness o Poor Memory o Tongue ulcers

o Insomnia o Easily confused o Lack of focus o Hard to fall asleep o Anxiety o Difficult to stay asleep o Restlessness o Mood Swings o Easily overheat or chills o Slight exertion causes heat o Fainting o Chest pain o Irregular heartbeat o swelling of hands/feet o Shortness of breath o Mania/delirium oDream disturbed sleep o Hot flashes

Gastrointestinal Stomach/Spleen

Mouth: o Bleed gums o Sour regurgitation o Tooth pain o Dry mouth o Drooling o Bad breath o Root canals x_____ o Silver fillings Appetite: o Poor o Always hungry o Weight gain o Weight loss o Fatigue after meals o Hungry with no desire to eat o Hungry after meals Cravings: o Bitter o Bland o Sweet o Sour o Salty Thirst: o Room temperature o Cold o Hot o No relief with drinks o Thirst with no desire to drink Fluids/nutrition: o Edema Heavy feeling in oBody oHead oLimbs Digestion: o Gas o Belching o Nausea o Vomiting o Cramps o Indigestion o Slow digestion o Abdominal distention o Bloating o Acid regurgitation Pain: Location: ________________________ o Worse after eating o Stress induced o Better with food Bowels: Bowel movement ____/day; ____wk. When? _______________ o Change in pattern o Constipation o Diarrhea o Brown o Black o Coffee grounds o Blood o Mucus o Undigested foods o Foul odor o Hard o Hemorrhoids o Anal itching o Anal bleeding o Sticky/pasty o Urgency o Unfinished feeling

Body: Temperature: o Cold hands o Cold feet o Lethargy o Organ prolapse o Easy bruising o Lack of muscle strength or tone in abdomen, back, neck Emotions: o Easily worried o Overwhelmed by details o Over thinking o Melancholy o Upset by change o Easily angered Gynecology and Pregnancy ___Age menses began ___Duration of flow ___ #live births ___Days of cycle ___# pregnancies ___# miscarriages Date of last period________________ Method of contraception______________________ Are you/could you be pregnant o Yes o No o Early menstrual cycle (<21 days) o Late menstrual cycle (> 35 days) o Irregular menstrual cycle Flow: o Light o Moderate o Heavy Color: o Light red o Dark red o Bright red o Purple o Brown Clots: o Small o Large o Few o Many o Dark

HIPAAComplianceDocument-ConcerningYourProtectedHealthInformation

THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY.

Thecoveredentityisrequiredbylawtomaintaintheprivacyofprotectedhealthinformationandtoprovideindividualswithnoticeofitslegalandprivacypracticeswithrespecttoprotectedhealth

information;

Forpurposesofthisnotice,theterm“coveredentity”referstoLotusPathWellnessCenter,Dr.MariaBelluccio,andofficestaff.

DearPatient:Youhaverightsconcerningyourprivatehealthinformation,youraccesstothisinformationandtoknowhowthisinformationisusedbyouroffice.Youalsohaverightsrelatedtoourabilitytocontactyouconcerningyouractivityinourpractice,suchasrecallreminders,billing,andothermattersrelatedtohowwecommunicatewithyouandothersonyourbehalf.Pleaseunderstandthatthisofficeandeachandallofitsemployeesandassociatesmakeeveryeffortpossibletokeepconfidentialyourprivatemedicalinformationatalltimesandwithyourconsentonly,willsuchinformationeverbesharedwithothers.

A.Thecoveredentitymaycontacttheindividualtoprovideappointmentremindersorinformationabouttreatmentalternativesorotherhealth-relatedbenefitsandservicesthatmaybeofinteresttotheindividual.B.Yourinformationwillnotbesharedwithanythirdpartywithoutyourexpresswrittenconsent.C.Yourrecordsareavailabletoyouforyourreview,copyingorcorrectionsbyappointmentandyouwillnotbedeniedaccesstoyourpersonalhealthinformation.Anychangesyourequesttoyourpersonalhealthinformationmustbesuppliedtothisofficeinwritingandyouwillbeadvisedwithin30daysofanyobjectiontothecorrection,orthatthecorrectionhasbeenmade.D.Withrespecttootherprovidersrequestingyourpersonalhealthinformation,wewillrequireawrittenauthorizationforthereleaseofmedicalrecordssignedbyyou,detailingthename,addressandphonenumberoftherequestingphysicianorfacility.Undernocircumstancewillwediscussyourpersonalhealthinformationwithanyonewithoutyourexpresspermissioninwriting.(Thiswillofcourseexcludeanyofficestaffthathasnecessaryaccesstoyourrecord)

IhavereceivedacopyofthisPrivacyNoticePatientSignature__________________________________Date___________________PrintYourName_______________________________________