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 and will require a credit card to

schedule your initial consultation. Since a full 90 minutes is set aside for you, please

advise us within 24-48hours if you cannot make your scheduled appointment to avoid

a $50.00 cancellation fee. Additional appointments take 30 –60 minutes, based on

your needs. Signature______________________________________ Date_________________

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

______________________________________________________________________

Patient’s Agreement to Abide by

OFFICE POLICIES ____________________________________________________________

GENERAL INFORMATION Lotus Path Wellness Center office hours are from 9:00 a.m. to 5:00 p.m. Monday

through Wednesday. We are closed on Thursday and Fridays. 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. For new patients, a credit card must be provided to schedule your

initial consultation.

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

PATIENT REGISTRATION FORM To my patients: the information collected is confidential and will help me determine if the treatment offered here will help you. If I do not sincerely believe that your condition will respond satisfactorily, I will not accept your case. In order that I understand your condition properly, please be as accurate and legible as possible with completing the enclosed forms. NAME___________________________________Gender________ Marital Status___________ Date of Birth_____________________________ SS Number_____________________________ Address____________________________________City_______________State____Zip______ Home Phone___________________ Cell phone__________________ Other________________ Email address___________________________________________________________________ Employer______________________________________Occupation______________________ Business Address________________________________Bus.Phone_______________________ Family Physician________________________________Phone #_________________________ Emergency contact____________________________Relationship_______________________ Phone#______________________________________________________________________

Who referred you to my practice?__________________________________________________

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.

PATIENT HISTORY

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: Rapid Gradual

Quality: Dull Burning Sharp Heavy

Location: Joint Muscle Low back Under ribs

Fixed Moving Radiating

Headache: Location Side Top Occipital

Frontal

Frequency Daily 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

Alcohol Marijuana Stress

Tobacco Drugs Occupational Hazards

Exercise Type: ________________________ Frequency: _____________________

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

Accidents Depression Low Blood Pressure Seizures

AIDS/HIV Diabetes Lupus Stroke

Alcoholism Emphysema Measles Thyroid Disease

Allergies Epilepsy Multiple Sclerosis Tuberculosis

Anxiety Glaucoma Mumps Typhoid Fever

Appendicitis Goiter Pacemaker Ulcers

Arteriosclerosis Gout Pleurisy Varicose Veins

Arthritis Heart Disease Pneumonia Venereal Disease

Asthma Hepatitis Polio Whooping Cough

Cancer Herpes Prostate Disease Fibromyalgia

Carpal Tunnel High Blood Pressure Rheumatic Fever Other (specify)

Chicken Pox Irritable Bowl Scarlet Fever ________________

__________________

List Surgeries: Major Trauma:

___________________________________ ___________________________________

___________________________________ ___________________________________

___________________________________ ___________________________________

___________________________________ ___________________________________

___________________________________ ___________________________________

List Medications, Vitamins, Herbals: Please see Supplements and Pharmaceuticals form

Family Medical History

Arteriosclerosis Cancer High Blood Pressure Thyroid Disease

Asthma Depression Seizures

Alcoholism Diabetes Stroke

Review of Systems

Lung

Perspiration: Scant Profuse Daytime Nighttime

Upper body Lower Body Spontaneous Other_________

Nose: Stuffy Dry Congested Nosebleeds

Sinus infections Shortness of breath Difficulty inhaling

Difficulty exhaling difficult breathing while lying down Wheezing

Sneezing Frequent colds and flues Allergies

Emotions: Recent loss or long term grief waking 3-5 a.m. sadness

Cough: Dry Productive Hacking Non Productive

Sputum: Clear White Blood tinged Yellow

Green Rusty Amount: Copious

Scant Difficulty rising

Skin: Dry Itchy Moist Rashes

Acne Body hair loss Eczema Psoriasis

Dandruff Fungal infections

Kidney/Urinary Bladder

Urine: Light Dark Clear Cloudy

Sand and grit Bloody Strong order Sweet order

Frequency: __/day __/night Urgency Hesitancy

Week flow

Amount: Dribble Intermittent Intake = Output Urinary incontinence

Pain: Lower back Week knees Cold feet worse in a.m.

Worse in p.m.

Sexual desire: Low High Impotence Premature Ejaculation

Energy: Lack of stamina Need lots of sleep

Hearing: Hearing loss Tinnitus (low humming) Vertigo Dizziness

Hair: Loss/thinning Dry Premature gray

Liver

Eyes: Vision change Blurred Night Red

Dry Gritty Floaters Itchy

Watery Painful Pressure Vertex Headache

Bitter taste in the mouth

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

Week flow

Amount: Dribble Intermittent Intake = Output Urinary incontinence

Pain: Lower back Week knees Cold feet worse in a.m.

Worse in p.m.

Sexual desire: Low High Impotence Premature Ejaculation

Energy: Lake of stamina Needs lots of sleep

Hearing: Hearing loss Tinnitus (low humming) Vertigo Dizziness

Emotions: Fear Disgruntled Easily defeated Diminished motivation

Hair: Loss/thinning Dry Premature gray

Heart Palpitations Dizziness Poor Memory Tongue ulcers

Insomnia Easily confused Lack of focus Hard to fall asleep

Anxiety Difficult to stay asleep Restlessness Mood Swings

Easily overheat or chills Slight exertion causes heat Fainting

Chest pain Irregular heartbeat swelling of hands/feet

Shortness of breath Mania/delirium Dream disturbed sleep Hot flashes

Gastrointestinal Stomach/Spleen

Mouth: Bleed gums Sour regurgitation Tooth pain Dry mouth

Drooling Bad breath Root canals x_____ Silver fillings

Appetite: Poor Always hungry Weight gain Weight loss

Fatigue after meals Hungry with no desire to eat Hungry after meals

Cravings: Bitter Bland Sweet Sour Salty

Thirst: Room temperature Cold Hot No relief with drinks

Thirst with no desire to drink

Fluids/nutrition: Edema Heavy feeling in Body Head Limbs

Digestion: Gas Belching Nausea Vomiting Cramps

Indigestion Slow digestion Abdominal distention Bloating

Acid regurgitation

Pain: Location: ________________________

Worse after eating Stress induced Better with food

Bowels: Bowel movement ____/day; ____wk. When? _______________

Change in pattern Constipation Diarrhea

Brown Black Coffee grounds Blood

Mucus Undigested foods Foul odor

Hard Hemorrhoids Anal itching Anal bleeding

Sticky/pasty Urgency Unfinished feeling

Body: Temperature: Cold hands Cold feet

Lethargy Organ prolapse Easy bruising

Lack of muscle strength or tone in abdomen, back, neck

Emotions: Easily worried Overwhelmed by details Over thinking

Melancholy Upset by change 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 Yes No

Early menstrual cycle (<21 days) Late menstrual cycle (> 35 days)

Irregular menstrual cycle

Flow: Light Moderate Heavy Color: Light red Dark red

Bright red Purple

Brown

Clots: Small Large Few

Many Dark

HIPAA Compliance Document-Concerning Your Protected Health Information

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The covered entity is required by law to maintain the privacy of protected health information and to

provide individuals with notice of its legal and privacy practices with respect to protected health information;

For purposes of this notice, the term “covered entity” refers to Lotus Path Wellness Center,

Dr. Maria Belluccio, and office staff.

Dear Patient: You have rights concerning your private health information, your access to this information and to know how this information is used by our office. You also have rights related to our ability to contact you concerning your activity in our practice, such as recall reminders, billing, and other matters related to how we communicate with you and others on your behalf. Please understand that this office and each and all of its employees and associates make every effort possible to keep confidential your private medical information at all times and with your consent only, will such information ever be shared with others.

A. The covered entity may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual. B. Your information will not be shared with any third party without your express written consent. C. Your records are available to you for your review, copying or corrections by appointment and you will not be denied access to your personal health information. Any changes you request to your personal health information must be supplied to this office in writing and you will be advised within 30 days of any objection to the correction, or that the correction has been made. D. With respect to other providers requesting your personal health information, we will require a written authorization for the release of medical records signed by you, detailing the name, address and phone number of the requesting physician or facility. Under no circumstance will we discuss your personal health information with anyone without your express permission in writing. (This will of course exclude any office staff that has necessary access to your record)

I have received a copy of this Privacy Notice Patient Signature__________________________________ Date___________________ Print Your Name _______________________________________