Dr. Tracy Ransome, D.C.
3217 Highland Ave
Manhattan Beach, CA 90266
HIPAA Acknowledgement of Receipt
Our office is HIPAA Compliant and the staff has been trained in the HIPAA Privacy Act. We will do everything we can to protect your patient heath information, and we ask that you be respectful of other patients’ privacy as well.
OUR FINANCIAL POLICY
Effective September 28, 2015
Thank you for choosing Dr. Ransome as your healthcare provider. We are committed to your treatment being successful. Our office policy has been established to assure that the best health service can be provided to you and your family. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
Full payment is due at the time of service. We accept cash, check and most credit cards.
Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $25. For patients arriving more than 15 minutes late, you may be asked to reschedule your appointment or have a shortened session, and normal rates will apply. If the doctor is running late, you will receive your full appointment. Appointments are scheduled every 30 minutes. Please help us serve you better by keeping scheduled appointments. We do our best to run on time, but due to the nature of the practice, we sometimes run behind. If you have specific time constraints, please notify us at the time you schedule your appointment, and we will do our best to accommodate your needs.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
My signature below certifies that I have read and fully understand the Financial Policy. I agree to this Financial Policy, and agree to be solely and severally responsible for payment of all services rendered to myself and/or any member of my family.
Signature of Patient or Responsible Party:
COMPREHENSIVE HEALTH QUESTIONNAIRE
NOTE: This is a confidential record of your medical history and will be kept in this office.
Information contained herein will not be released pursuant to HIPAA regulations.
Were you adopted? YES NO Age at adoption:
Was your mother outwardly ill prior to her pregnancy with you? YES NO
Did your mother have any falls, accidents, or physical injuries during pregnancy? YES NO
Did your mother have a difficult pregnancy with you? YES NO
Was your birth traumatic? YES NO
Was your birth: “C” section Breech Natural Forceps or suction Cord around the neck Prolonged
Please describe any other stressors to your mother or you as labor progressed, delivery progressed, or as a newborn:
Was your mother regularly taking any drug immediately prior to, or during her pregnancy with you?
If yes: Alcohol Tobacco Other:
Was her labor chemically induced or altered? YES NO
During your delivery, was your mother:
conscious semiconscious unconscious under spinal anesthesia
Any other chemical stress that your mother may have been subject to during pregnancy or labor?
My birth was: at home in a birthing center in a hospital other:
Were you incubated or isolated after birth? YES NO
Were you (check all that apply):
bottle fed formula bottle fed mother’s milk nursed other:
GENERAL PHYSICAL STRESS
Next to each potential vertebral subluxation cause is a check box. Please check the appropriate box – either P for past or C for current, and the correct level of stress: Mild, Moderate or Extreme
Were you ever knocked unconscious? YES NO
Have you ever used crutches, a walker, or cane? YES NO
Have you ever had any impacts, falls or jolts that you feel may have injured your spine? YES NO
Have you had extensive dental or orthodontia work performed? YES NO
Have you had served in the military? YES NO
If yes, from to
Were you involved in combat? YES NO
Are you: Right handed Left handed Ambidextrous
Do you wear: Glasses Bifocals Contact lenses Other: None of these
During the day, do you:
sit stand walk do desk work do phone work drive do mechanical work heavy lifting
Do you exercise: daily weekly monthly never
SPORTS AND LEISURE
Were you, or are you, active in any particular sport(s)? YES NO
Have you been hurt in any of these activities? YES NO
Do you read for prolonged periods? YES NO
Do you play a musical instrument? YES NO
Do you have a particular position for watching television?
Any other activities you participate in regularly?
Have you (even as a passenger and even if you do not think you were hurt) been involved in a vehicular collision, or near collision?
Please list approximate dates and severity (Mild, Moderate, or Extreme):
Bus, bicycle, motorcycle, train. Airplane, or other vehicles:
Have you ever been hospitalized? YES NO
If yes, please explain:
Have you ever had surgery? YES NO
If yes, please explain:
Do you still have all your body parts? YES NO
If no, please explain:
Have you ever had:
Are you now taking any drug (prescription or over-the-counter) regularly? Please list drugs, when prescribed, and reasons for taking them:
If you were previously taking any medication regularly, please describe:
Do you now, or have you ever, used non-prescription drugs? YES NO
Do you or did you work with any chemical, fume, dust, powder or smoke for prolonged periods? YES NO
Using the following scale, please grade any dietary selection that is appropriate for you:
|O – Do not consume this
||M – Consume this monthly
|FM – Consume this a few times per month (less than weekly)
||FW – Consume this a few times per week
|W – Consume this weekly
||FD – Consume this a few times per day
|D – Consume this daily
Do you ever fast? YES NO
The type of diet I usually follow is classified as:
GENERAL EMOTIONAL STRESS
With each of the following potential spinal stress situations, please check either “P” for past or “C” for current:
How do you grade your physical health? Excellent Good Fair Poor Getting better Getting worse
How do you grade your emotional health? Excellent Good Fair Poor Getting better Getting worse
If you consider yourself ill, why do you feel you are ill?
If you consider yourself well, why do you feel you are well?
Is there anything else you may wish to share, which may help us to better understand you and why you have chosen to see the doctor in this office?
FAMILY HEALTH HISTORY
Please check if any blood relative has ever had:
REVIEW OF SYSTEMS
Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems may affect your overall course of care, as well as be signs of less than optimal function.
Please circle P for having had the issue in the past, or N for issues that are affecting you now:
NETWORK SPINAL ANALYSIS™ (NSA)
Thrive Holistic Wellness
I hereby request and consent to receiving spinal care, including wellness education in this office by a chiropractor(s) who provides Network Spinal Analysis (NSA) Care, a low force approach which has unique outcomes and clinical results. This practitioner(s) chooses to practice NSA, as he/she 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 Practice Guidelines and the Canon of Ethics of the Association for Network Care. My doctor(s) has been trained in traditional chiropractic care and certified in the procedures of Network Spinal Analysis 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 care, re-assessments 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 to re-organize 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 re-distribution 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:
It has been explained to my satisfaction, and I understand that the 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 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.
It is common for people receiving NSA care to breathe more deeply and more fully, engaging the spine with their respiration, to spontaneously adapt postures that release or redistribute tension, to bust stress, and to experience more of their inner life energy. I understand it is common to experience a wider range of motion and emotion during care. It is common, as care progresses, to find new options in the body and in life, which often lead to significant life changes.
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 the body-mind, emotion, and consciousness.
Rather than attempting to simply return me to my previous state minus a symptom, this practitioner instead chooses to help me achieve new levels of wellness and life potential that I may never have had before.
I have read, or have had read to me, the CONSENT TO RECEIVE NETWORK SPINAL ANALYSIS (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.
Name of Practice Member:
Signature of Practice Member: