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

drginni@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

drginni@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