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Touch Light Chiropractic
Dr. Ginni Gross, D.C.
16405 Northcross Dr. Ste. D Huntersville, NC 29078
Tel: 704-885-5770 Fax: 704-997-8137
www.touchlightchiro.com
Name Home Phone __________________________
Address Work Phone
City, State, Zip Cell Phone
E‐mail Address
Birth date Age Occupation
Employer
Status: Married Widowed Separated Divorced Single Spouse Name No. of Children _____
To conserve resources, we generally utilize email and text for regular communication. May we communicate with you via? Email: Text: Carrier (like AT&T, Etc.): _______________________________________________
Most patients are referred to our office by a caring family member or friend. What made you to decide to visit our office?
Friend Family Member Name: ___________________________________________________________Telephone Call website presentation Email
Please answer the following questions: 1. Spinal problems can cause a variety of health problems. Please check the health complaint(s) you are currently
experiencing or experience on a periodic basis:
Low Back Pain Arm or Hand Pain Carpal Tunnel Syndrome Indigestion
Upper/Mid Back Pain Leg or Foot Pain Ear Infections Chronic Fatigue
Neck Pain Asthma Frequent Colds Arthritis
Shoulder Pain Allergies/Sinus Spinal Curvature Fibromyalgia Other (e.g. Headache, Anxiety/Depression, or Sleep Problems )____________________________________________
2. Please list the health concerns you are experiencing: 1. _____________________________ 2.________________________________ 3._____________________________________
3. Auto and work injuries can cause serious spinal problems. Is this visit related to an auto or work injury? Yes No 4. Research shows that your spine should be checked regularly. When was your last complete Spinal examination?
within the last year 1 ‐ 5 years 5 years or longer Never 5. Have you ever been told that you have a spinal curvature, spinal arthritis, or inherited spinal problem?
YES NO If yes, circle one of the above and explain_________________________________ 6. Long term spinal misalignments can cause decay and arthritis in the spine which may result in grinding or popping
noises. Do you ever hear grinding or popping noises when you move your head or neck? YES NO 7. Spinal misalignments can make you feel like you need to twist, stretch or crack your neck or back. Do you ever feel the
need to twist, stretch or crack your neck, mid or lower spine? YES NO 8. Poor posture can lead to poor health and usually indicates a spinal problem. How would you rate your posture?
Poor ‐ 1 2 3 4 5 6 7 8 9 10 ‐ Very Good
9. Stress can cause or aggravate spinal problems. Please rate your stress levels over the last 90 days. Low ‐ 1 2 3 4 5 6 7 8 9 10 ‐ High
10. Are you currently taking prescription medication? YES No If so, how many? _______
11. Spinal health is especially important during pregnancy. If female, is there any chance that you are pregnant? YES NO MAYBE. If yes, when is your due date? Or Date of Last Cycle? _____________
12. Have you ever been diagnosed with cancer? YES NO If so, what kind?____________ Year diagnosed __________
13. Have you ever had spinal surgery? YES NO If yes, year and level? __________________________________
14. If the doctor feels that you will benefit from chiropractic care, are you willing to follow his/her recommendations? YES NO
15. How will you be paying for today’s visit? Credit/Debit Card Cash Check Other
16. Are you Medicare eligible?YES NO
17. How is your health condition preventing you from doing activities? _____________________________________
18. How would your life change if you have optimal health? ________________________________________________________
19. What needs to happen for you to have optimal health? __________________________________________________ The above information is true and accurate to the best of my knowledge. I f X - r a y e d , copies of any X‐rays and reports will be released
upon written request, however original X‐rays remain the property of the clinic.
Adult New Patient Application “A Healthy Spine Means a Healthier You!”
Signature: Date
Wellness & Quality of Life Survey N a m e : D a t e :
P l e a s e c i r c l e t h e n u m b e r t h a t b e s t d e s c r i b e s y o u r c u r r e n t e x p e r i e n c e .
I . Physical State H o w o f t e n d o y o u e x p e r i e n c e t h e f o l l o w i n g s y m p t o m s ?
Never Rarely Occasionally Regularly Constantly
1 . P l i y s i c a l P a i n ( n e c k / b a c k a c h e , s o r e a r m s / l e g s , e t c . ) . 1 2 3 4 5
2 . F e e l i n g o f t e n s i o n , s t i f f n e s s o r l a c k o f f l e x i b i l i t y . 1 2 3 4 5 3 . F a t i g u e o r l o w e n e r g y . 1 2 3 4 5
4 . C o l d s a n d f l u . 1 2 3 4 5
5 . H e a d a c h e s ( o f a n y k i n d ) . 1 2 3 4 5
6 . H e a r t b u r n o r i n d i g e s t i o n . 1 2 3 4 5
7 . N a u s e a o r c o n s t i p a t i o n . 1 2 3 4 5
8 . M e n s t r u a l d i s c o m f o r t . 1 2 3 4 5
8 . A l l e r g i e s o r s k i n r a s h e s . 1 2 3 4 3
9 . D i z z i n e s s o r l i g h t - h e a d e d n e s s . 1 2 3 4 5
1 0 . A c c i d e n t s o r n e a r a c c i d e n t s o r f a l l i n g o r t r i p p i n g . 1 2 3 4 5
1 1 . E a s e o f r e c o v e r y f r o m i n j u r ) ' . 1 2 3 4 5
1 2 . R e s t r i c t e d o r s h a l l o w b r e a t h i n g . 1 2 3 4 5
I I . Mental/Emotional State R a t e t h e f o l l o w i n g q u e s t i o n s w i t h r e s p e c t t o f r e q u e n c y :
Never Rarely Occasionally Regularly Constantly
1 . I f p a i n i s p r e s e n t , h o w d i s t r e s s e d a r e y o u a b o u t i t ? 1 2 3 4 5
2 . P r e s e n c e o f n e g a t i v e o r c r i t i c a l f e e l i n g s a b o u t y o u r s e l f . 1 2 3 4 5
3 . E x p e r i e n c e o f m o o d i n e s s , t e m p e r o r a n g e r o u t b u r s t s . 1 2 3 4 5
4 . E x p e r i e n c e o f d e p r e s s i o n o r l a c k o f i n t e r e s t . 1 2 3 4 5
5 . O v e r r e a c t i n g t o h f e ' s s t r e s s e s . 1 2 3 4 5
6 . B e i n g o v e r l y w o r r i e d a b o u t s m a l l t h i n g s . 1 2 3 4 5
7 . E x p e r i e n c e o f v a g u e f e a r s o r a n x i e t y . 1 2 3 4 5
8 . D i f f i c u l t y t h i n k i n g o r c o n c e n t r a t i n g o r i n d e c i s i v e n e s s . 1 2 3 4 5
9 . D i f f i c u l t y f a l l i n g o r s t a y i n g a s l e e p . 1 2 3 4 5
1 0 . E x p e r i e n c e o f r e c u r r i n g t h o u g h t s o r d r e a m s . 1 2 3 4 5
I I I . Stress Evaluation E v a l u a t e y o u r s t r e s s r e l a t i v e t o t h e f o l l o w i n g :
None Slight Moderate Considerable Extensive
1 . F a m i l y . 1 2 3 4 5
2 . S i g n i f i c a n t O t h e r . 1 2 3 4 5
3 . P h y s i c a l H e a l t h . 1 2 3 4 5
4 . F i n a n c e s . 1 2 3 4 5
5. S e x L i f e . 1 2 3 4 5
6 . W o r k o r S c h o o l . 1 2 3 4 5
7 . C o p i n g w i t h d a i l y p r o b l e m s . 1 2 3 4 5
I V . Life Enjoyment R a t e t h e f o l l o w i n g s t a t e m e n t s w i t h r e s p e c t t o f r e q u e n c y :
Never Rarely Occasionally Regularly Constantly
1 . O p e n n e s s t o g u i d a n c e f r o m y o u r " i n n e r v o i c e / f e e l i n g s " . 1 2 3 4 5
2 . E x p e r i e n c e o f p e a c e , r e l a x a t i o n , e a s e o r w e l l - b e i n g . 1 2 3 4 5
3 . P r e s e n c e o f p o s i t i v e f e e l i n g s a b o u t y o u r s e l f . 1 2 3 4 5
4 . I n t e r e s t i n m a i n t a i n i n g a h e a l t h y l i f e s t y l e ( e . g . , d i e t , f i t n e s s , e t c . ) . I 2 3 4 5
5 . F e e l i n g o f b e i n g o p e n , a w a r e a n d c o n n e c t e d w h e n r e l a t i n g t o o t h e r s 1 2 3 4 5
6 . L e v e l o f c o n f i d e n c e i n y o u r a b i l i t y t o d e a l w i t h a d v e r s i t y . 1 2 3 4 5
7 . L e v e l o f c o m p a s s i o n f o r a n d a c c e p t a n c e o f o t h e r s . 1 2 3 4 5
8 . E x p e r i e n c e f e e l i n g s o f j o y o r h a p p i n e s s . 1 2 3 4 5
9 . E x p e r i e n c i n g g r a t i t u d e . 1 2 3 4 5
1 0 . L e v e l o f s a t i s f a c t i o n w i t h y o u r s e x h f e . 1 2 3 4 5
1 1 . S a t i s f a c t i o n w i t h t h e l e v e l o f r e c r e a t i o n i n y o u r l i f e . 1 2 3 4 5
1 2 . T i m e d e v o t e d t o t h i n g s y o u e n j o y . 1 2 3 4 5
V . Overall Quality of Life E v a l u a t e y o u r f e e l i n g s r e l a t i v e t o y o u r q u a l i t y o f l i f e :
Unhappy Mostly
Dissatisfied Mixed Mostly
Satisfied Delighted
1 . Y o u r p e r s o n a l l i f e . 1 2 3 4 5
2 . Y o u r w i f e / h u s b a n d o r " s i g n i f i c a n t o t h e r " . l 2 3 4 5
3 . Y o u r r o m a n t i c l i f e . 1 2 3 4 5
4 . Y o u r j o b . 1 2 3 4 5
5 . Y o u r c o - w o r k e r s . 1 2 3 4 5
6 . T h e a c t u a l w o r k y o u d o . 1 2 3 4 5
7 . T h e h a n d l i n g o f p r o b l e m s i n y o u r h f e . 1 2 3 4 5
8 . W h a t y o u a r e a c t u a l l y a c c o m p l i s h i n g i n y o u r l i f e . 1 2 3 4 5
9 . Y o u r p h y s i c a l a p p e a r a n c e - t h e w a y y o u l o o k . 1 2 3 4 5
1 0 . Y o u r a b i l i t y t o a d a p t t o c h a n g e i n y o u r l i f e . 1 2 3 4 5
1 1 . O v e r a l l c o n t e n t m e n t w i t h y o u r l i f e . 1 2 3 4 5
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Informed Consent to Receive Network Spinal Analysis TM (NSA) Care I hereby request and consent to receiving spinal care, including wellness education in this office by a
chiropractor, Ginni Gross who provides Network Spinal Analysis (NSA) Care, a low force approach
which has unique outcomes and clinical results. The practitioner(s) chooses to practice NSA, as Dr. Ginni
is professionally and personally confident in regard to the safety and effectiveness of this form of care.
This office provides care in accordance with the Council on Chiropractic Guidelines and the Canon of
Ethics of the Association for Reorganizational Healing Practice, and my doctor(s) has been trained in
traditional chiropractic care and certified in the procedures of Network Spinal Analysis (NSA) Care.
The purpose of this consent form is to help me better understand the nature of the services offered in this
office and our mutual responsibilities. This fosters a more effective relationship and avoids
misunderstandings regarding expectations. Having well understood expectations is anticipated to promote
a greater sense of safety and healing.
NSA does not attempt to manually, or by instrument, manipulate spinal fixations structurally (often
associated with a snapping or popping sound), nor does it directly treat painful areas of the spine and
body. Instead, by enhancing my body’s awareness of itself and specifically my spine, I understand I
can develop new strategies for healing, adapting to stress, and experiencing wellness. These strategies
promote spontaneous self-correction and self-regulation of spinal tension patterns and healing.
NSA consists of gentle touch contacts along the neck and back to achieve greater communication between
the brain and body, and new sensory and motor strategies. NSA adopts an approach associated with
somatic (body/spinal awareness) training. There is a body of research characterizing NSA care and
documenting its unique and significant wellness benefits. I understand I may obtain copies of published
research articles and/or abstracts in this office.
I am aware that I will be receiving gentle touch Network Adjustments, also called Entrainments.
Assessments of my progress will include monitoring of my spine and body awareness, responsiveness to
inner rhythms, tension, and ease patterns. At regular intervals, following commencement of my care,
reassessments will be performed. These will include my personal perception of my wellness and my
awareness of my spine and body-mind changes. My chiropractor(s) will report to me the improvement in
my spinal and nervous system integrity and my ability to self-regulate tension and reorganize my spine.
NSA is advanced through a series of Levels of Care. Each Level of Care involves the development of
new and unique spontaneous spinal wave motions, other body movements, and oscillations. These waves,
which are suggested to be associated with the greater spinal stability, the redistribution of energy, and the
transfer of internal information, are also associated with greater wellness, improved quality of life, and
increased life enjoyment.
I also understand that, in addition to NSA care and wellness education, my practitioner(s) may perform
additional examinations or assessments and offer health/spinal care or advice that is consistent with my
individual needs.
Please read and sign the following:
I hereby request and consent to the performance of Network Entrainments/Adjustments, including
wellness education and any supportive healing modalities on me (or on the practice member named
below, for whom I am legally responsible) by the doctor of chiropractic, Ginni Gross, and/or other
licensed doctors of chiropractic and support staff who now or in the future treat me while employed by,
working or associated with or serving as back-up for the doctor of chiropractic, Ginni Gross, including
those working at Touch Light Chiropractic or any other office, whether signatories of this form or not.
It has been explained to my satisfaction, and I understand that care offered at this office is not a form of,
or replacement for, the diagnosis or treatment of any symptom, disease or malady. Instead, it is a form of
704.885.5770
touchlightchiro.com
16405 Northcross Dr. | Ste. D | Huntersville, NC 28078
wellness care and self-education that empowers my connection with my body-mind and develops new
strategies for spinal and nervous system integrity and wellness. It develops new capacities in my body for
the identification of, spontaneous release of, and redirection of tension, including those that are unique to
NSA care.
I have had the opportunity to discuss with the doctor of chiropractic, Ginni Gross, and/or with other office
personnel, the nature and purpose of the Network Spinal Analysis (NSA) Care offered in this office. I
understand results are not guaranteed and there is no promise of cure.
This form of care is NOT suggested for those individuals who wish to remove a symptom or condition
without the occurrence of other fundamental changes in their lives. The care in this office often
promotes significant changes in health choices, lifestyle, experience of body-mind, emotion, and
consciousness.
Rather than attempting to simply return me to my previous state minus a symptom, this chiropractor
instead chooses to help me achieve new levels of wellness and life potential that I may never have had
before.
Although in this office we seek to develop new strategies for wellness and spinal and nervous system
integrity, as a chiropractor the sole condition of concern is that of vertebral subluxation. In NSA care, we
categorize these subluxations into two categories, a structural segmental distortion and a spinal cord/nerve
elongation or stretching. Through the gentle force applications at the spine to enhance spinal and nervous
system integrity, subluxations are corrected. The only condition we offer to diagnose and correct is
vertebral subluxation and loss of spinal and neural integrity in relationship to this. We do not offer to
diagnose or treat any other condition, disease, or symptom. If during the course of our spinal
assessment/examination we encounter non-chiropractic or unusual findings, we will advise you of this. If
you desire advice on further diagnosis or treatment of this condition, situation or circumstance, we will
recommend that you seek the services of another health care provider whose practice is geared towards
such differential diagnosis and treatment.
I further understand and have been informed that there are other treatment options available to me other
than the Network Spinal Analysis (NSA) Care provided in this office and that I have the right to a second
opinion and to secure other options if I have concerns to the nature of my symptoms and treatment
options.
I have read, or have had read to me, the Consent to Receive Network Spinal Analysis TM (NSA) Care
and understand that the care in this office is different from what many consumers may expect from
chiropractors practicing manipulative therapy. I agree to receive care, which consists of or includes
NSA care and wellness education. I understand that I am not passive in this process, but that I am an
active participant in my care and in my healing.
______________________________________ ___________________________________ Signature of Practice Member (Or Guardian, Parent, Representative) Print Name and Relationship if signing for Practice Member
______________________________________ ___________________________________
Printed Name of Practice Member Date ___________________________________________________________
Printed Name of Witness
___________________________________________________________ __________________________________________________
Signature of Witness Date
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THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Touch Light Chiropractic, (the “Practice”) is committed to maintaining the privacy of your protected health
information (“PHI”), which includes information about your health condition and history as well as the care and
treatment you receive from the Practice and other health care providers. This notice details how your PHI may be
used and disclosed to third parties for purposes of your care, payment of your care, health care operation of the
practice and for other purposes permitted or required by law. This notice also details your rights regarding your
PHI.
This Practice employs multiple doctors of Chiropractic and practitioners at any given time. However for purposes of
compliance with the Health Information Portability and Accountability Act (HIPAA) Privacy rules, all doctors are
deemed to be a part of a single Organized Health Care Arrangement, which means that they operate as an
integrated unit; that they will share protected health information in order to carry out chiropractic care (including
coverage for each other), payment for services rendered and health care operations; that this notice provided
serves as a joint notice made by each doctor, practitioner and staff person and that each of them will abide by the
terms of this notice.
We provide most on-going care in an “open adjusting/entrainment” area. It is NOT the environment used for taking
patient histories, performing examinations or presenting reports of findings. These procedures are completed in a
private, confidential setting. This means that statements made by you or employees of the Practice during
treatment may be overheard by others. There are various interpretations under federal law with respect to what is
known as “incidental disclosures” of health information. It is our view that the kinds of matters related in an “open
adjusting/entrainment” environment are incidental matters. If you have comments or information you wish to
share privately when you come into the entrainment room please inform the doctor or staff and we will
accommodate your needs.
In the course of your care at Touch Light Chiropractic, we may use or disclose personal and health related
information about you in the following ways:
*Your PHI, including your clinical records may be disclosed to another health care provider or hospital if it is
necessary to refer you for further diagnosis, assessment or treatment.
*Your name, address, phone number and health care records may be used to correspond with you during or after
your care. This may include contacting you regarding: appointment reminders, recommendation notices, birthdays,
holiday, referral thank-you, practice events, or other health related information (i.e. Newsletters, e-mails, etc.) that
may be of interest to you, as well as other similar correspondence.
Further you have the right to inspect or obtain a copy of the information we will use for these purposes. If you are
not at home to receive an appointment reminder call, a message may be left on your answering machine. You also
have the right to refuse to provide authorization for this office to contact you regarding these matters. This request
must be made in writing. If you do not provide us with this authorization it will not affect the care provided to you
or the reimbursement avenues associated with your care.
704.885.5770
touchlightchiro.com
16405 Northcross Dr. | Ste. D | Huntersville, NC 28078
Under federal law, we are also permitted or required to use or disclose your health information without your
consent or authorization in the following circumstances:
*If we are providing health care services to you based on the orders of another health care provider.
*If we provide health care to you in an emergency or if we are required by law to provide care and are unable to
obtain your consent after attempting to do so.
*If we are ordered by courts or another appropriate agency. Also, when required by law (i.e. case of child abuse
and neglect) or for special government functions (i.e. military, veteran) and correctional institutions in the case of
inmates.
*If you are involved in a Workers’ Compensation claim, we may be required to disclose your PHI to an individual or
entity that is part of the Workers’ Compensation system.
*If we contract with a business associate to provide a service necessary for your treatment, payment for your
services, and health care operations (i.e. practice or front desk coverage, billing or transcription service, etc.).
Any use or disclosure of your PHI, other than as outlined above, will only be made upon your written authorization.
We normally provide information about your health care to you in person at the time you receive chiropractic care
from us. We may also mail information to you regarding your health care or about the status of your account. If
you would like to receive this information at an address other than your home please advise us in writing.
You have the right to inspect or request a copy of your PHI for seven years from the date the record was created or
as long as the information remains in our files. In addition you have the right to request an amendment to your
health information. The Practice has 30 days to comply. Requests to inspect, copy, or amend your health related
information must be made in writing.
We are required by law to maintain the privacy of your patient file and the PHI therein. We are also required to
provide you with this notice of our privacy practices with respect to your PHI and to abide by the terms of this
notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are
made we will notify you in writing as soon as possible following the changes.
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities
please let our staff know.
Your signature indicates your authorization of the policies outline in this notice.
______________________________ Name (printed) ______________________________ Signature
______________________________ Date