Dr. Janine Lex A functional Medicine Practice Pg_ Other (Yoga, Pilates) _ Avg intensity of...

3061 Brickhouse Court, Ste 107

Virginia Beach, VA 23452

757.491.2598

Vitality757.com [email protected]

A f u n c t i o n a l M e d i c i n e P r a c t i c e

D r . J a n i n e L e x

Today's Date: __________________

First Name: ______________________________MI: _____ Last name: __________________________

email Address: _________________________________________ Approved for messages?

Mobile Phone: __________________________________________ Approved for messages?

Home Phone: _______________________________Office phone: _____________________________

Address: _________________________________________________City: _________________________

State: _______ Zip code: ____________________ Referred By: ______________________________

Date of Birth: _____________________________ age: ________ Occupation: __________________

Emergency Contact: _____________________________________ Phone: ______________________

Relationship: ____________________________________________

Please describe the reason for today’s visit.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Briefly describe your top 3 health goals.

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

3. _______________________________________________________________________________________

Physical Data

Current Height: _________ what was your height in your early 20’s? __________

Current Weight: _________ Ideal Weight: ________

Frame: xs s m l xl xxl

P g . 1

Functional Medicine * The office of Dr. Janine Lex 3061 Brickhouse Court, STE 107 * Virginia Beach, VA 23452

757.491.2598 * www.Vitality757.com * [email protected]

Nutrition

Check if apply

Exercise

Type of workout (% of each) workout details

______ Cardio / Aerobic ______ avg number of workouts per week

______ Strength Training ______ Avg time per workout

______ Other (Yoga, Pilates) ______ Avg intensity of workout

Do you feel fatigued after exercise? Yes No

Energy and Sleep

Energy Level

Sleep Pattern

_______ Length of time falling asleep (minutes)

_______ Hours slept before first time waking (hours)

_______ Average time slept each night (Hours)

Do you dislike healthy food?

Are you an emotional eater?

Do you overeat under stress?

Do you eat too little under stress?

Do you eat mostly non-organic foods?

Do you drink fewer than 8 glasses of water per day?

Do you use caffeine? (coffee, soda, tea, energy drinks, etc) How many per day? ____

Do you take antacids frequently?

Do you take lactose intolerance pills frequently?

Do you regularly use acid-clocking drugs? (Tagamet, Zantac, Prilosec, ect)

Time ________ when you wake up

Time ________ Mid morning

Time ________ Lunch

Time ________ Mid-day

Time ________ Dinner

Time ________ Late at night

Time ________ Bedtime

1 2 3 4 5 n/a

Low -————————————–——High

Pg. 2

None ——————————————- severe Never —————————————-- always



Sleep problems

Check if apply

Stress

Stressors

Do you snore?

Do you wake with a headache?

Do you wake feeling tired / not rested?

Do you have trouble falling asleep?

Do you wake up often throughout the night?

Do you have trouble falling asleep once awakened?

Do you use a sleep apnea device?

Do you take herbal ir over-the-counter sleep aids?

Do you kick or jerk your legs and/or arms while asleep?

Do you ever awake choking, gasping for air, or feeling smothered?

Do you experience restlessness, tingling, or crawling in your arms or legs?

Do you experience the inability to keep your legs still prior to falling asleep?

As an adult, have you had episodes of talking in your sleep?

AS an adult, have you had episodes of sleep walking?

Does your heart pound at night?

Do your children cause you stress?

Does your spouse / significant other cause you stress?

Do financial concerns cause you stress?

Does your job cause you stress?

Do you feel you have an excessive amount of stress in your life?

Do you feel you can easily handle the stress in your life?

Have you ever been abused, the victim of a crime, or had significant trauma?

Have you experienced major losses in your life?

Please List anything else which causes you stress

______________________________________________________________

______________________________________________________________

1 2 3 4 5 n/a

Pg. 3



Stress Management

Please list things that you do to relive stress: _______________________________________

__________________________________________________________________________________________

Allergies / Exposure

Yes No Sometimes

Do you pray or meditate?

Do you exercise?

Do you get enough sleep?

Drug allergies: (Please list)

__________________________________________________________________________________________________

Environmental allergies (check for yes)

Aerosol (cologne, smoke, cleaning fluids)

Seasonal (ragweed, Pollen, dust)

Pet / animal

Latex

Any not listed? ___________________________________________________________________________

Food Allergies (Check for yes)

Grain (corn, wheat, rye, barley, spelt, ect)

Gluten

Dairy / Lactose

Nuts

Shellfish

Soy

Eggs

Yeast

Do you react adversely to caffine?

Do you react adversely to food preservatives?(sodium benzoate, MSG, Sulfites, ect)

Radiation

Exposure — have you been or are you exposed to any of the following (check for yes)

Radon

Second-Hand smoke

Asbestos

Lead

Mercury

Coal

Electronics (power lines, wi-fi, cell phone, EMF)

Artificial Sweeteners

Toxic chemicals (solvents, pesticides)

Mold

Plastics (water bottles, food containers)

Pg. 4



Medications & Supplements

Please list all current Prescription medications

Name Strength How Many How often / when

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

Please list all over the counter medications


_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

Please list all current Vitamins & supplements


_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________

_______________________________ __________ ___________ _______________________________ Check for yes

______ Have you had prolonged or regular use of NSAID’s? (Advil, Aleve, Motrin, Aspirin, Tylenol, ect)

______ Have you had prolonged or regular use of antibiotics

______ Have you had prolonged or regular use of steroids? (prednisone, nasal allergy inhalers)

Pg. 5



Medical History

Check if apply (either past or current)

Asthma

Chronic Bronchitis

Emphysema (COPD)

Pulmonary Hypertension

Chronic Sinusitis

Pneumonia

Sleep apnea

Tuberculosis

Blood pressure

High blood pressure

Low blood pressure

Blood clots

Hemophilia

Factor v Leiden

Coronary artery disease

Heart attack

Congestive heart failure

Coronary artery blockage

Carotid artery stenosis

arrhythmia

High Cholesterol

High triglycerides

Reflux (heartburn)

Stomach ulcers

Gall Bladder Disease

Liver disease

IBS

Crohn’s disease

Ulcerative colitis

Celiac disease

Elevated blood sugar (pre-diabetic)

Diabetes (youth onset, treated with insulin)

Diabetes (adult onset, treated with diet)

Diabetes (Adult onset, treated with insulin)

Obesity

Overweight

Underweight

Anorexia

Bulimia

Low thyroid (Hypothyroidism)

Hashimoto’s thyroiditis

High Thyroid (Hyperthyroidism)

Thyroid nodules

Graves disease

Goiter

Stroke

Migraines

Seizures

ADD / ADHD

Brain injury / concussion

Depression

History of suicide attempts

Anger management problems

Bipolar disorder

Post-Traumatic stress disorder

Arthritis

Rheumatoid arthritis

Gout (arthritis)

OSteopenia (weakening bones)

Osteoperosis (weak bones)

Pg. 6



Medical History Social History Check if apply (either past or current)

Occupational Status: __________________

Occupation: _____________________________

Name of Company: _______________________

Marital Status: _________________________

Partner Name: __________________________

Use Tobacco? Yes no ________ Year Quit

Use Alcohol? Yes No In recovery

Other substances? Yes No

Do you have a history of using street or recreational drugs?

Yes No

Do you currently use recreational or street drugs?

Yes No

Have you traveled outside of the US? Yes No

HIV

Hepatitis

Herpes

Mononucleosis (CMV)

Epstein-Barr Virus

Multiple Sclerosis

Lupus SLE

Chronic Fatigue syndrome

Fibromyalgia

Breast Cancer

Prostate Cancer

Testicular cancer

Colon Cancer

Skin Cancer

Lung cancer

Bladder Cancer

Kidney Cancer

Thyroid Cancer

Pancreatic cancer

Lymphoma Cancer

Leukemia cancer

Other cancer

Eczema

Hives

Athlete’s foot

Psoriasis

Acne

Vitiligo

Enlarged prostate

Impotency treatments

Surgical History

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Type __________________________________ year _________

Pg. 7



Family History (Biological Only)

living/deceased/

Family member unknown Age Cause of death

Mother _______________ ________ _________________

Father _______________ ________ _________________

Maternal Grandmother _______________ ________ _________________

Maternal Grandfather _______________ ________ _________________

Paternal Grandfather _______________ ________ _________________

Paternal Grandmother _______________ ________ _________________ Please place an "x" under any family members with known medical problems

NONE UNSURE MOTHER FATHER BROTHER SISTER GRAND-MOTHER

GRAND- FATHER

AUNT UNCLE

Breast Cancer

Ovarian Cancer

Uterine Cancer

Prostate Cancer

Colon Cancer

Heart Attack

Heart Disease

High Cholesterol

High Blood Pressure

Diabetes

Stroke

Obesity

Thyroid Disease

Kidney Disease

Liver Disease

Lung Disease

Osteoporosis

Alzheimer's Dementia

Mental Illness

Alcoholism

Drug Abuse

Pg. 8

Medical Symptoms Questionnaire (MSQ)

Patient Name _______________________________________________________________ Date ___________________

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale 0 – Never or almost never have the symptom1 – Occasionally have it, effect is not severe 2 – Occasionally have it, effect is severe

__________ Headaches __________ Faintness __________ Dizziness __________ Insomnia Total _________

__________ Watery or itchy eyes __________ Swollen, reddened or sticky eyelids __________ Bags or dark circles under eyes __________ Blurred or tunnel vision Total _________

(Does not include near or far-sightedness)

__________ Itchy ears __________ Earaches, ear infections __________ Drainage from ear __________ Ringing in ears, hearing loss Total _________

__________ Stuffy nose __________ Sinus problems __________ Hay fever __________ Sneezing attacks __________ Excessive mucus formation Total _________

__________ Chronic coughing __________ Gagging, frequent need to clear throat __________ Sore throat, hoarseness, loss of voice __________ Swollen or discolored tongue, gums, lips __________ Canker sores Total _________

__________ Acne __________ Hives, rashes, dry skin __________ Hair loss __________ Flushing, hot flashes __________ Excessive sweating Total _________

__________ Irregular or skipped heartbeat __________ Rapid or pounding heartbeat __________ Chest pain Total _________

3 – Frequently have it, effect is not severe 4 – Frequently have it, effect is severe

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

HEAD

Pg. 9

MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)

__________ Chest congestion __________ Asthma, bronchitis __________ Shortness of breath __________ Difficulty breathing Total _________

__________ Nausea, vomiting __________ Diarrhea __________ Constipation __________ Bloated feeling__________ Belching, passing gas __________ Heartburn __________ Intestinal/stomach pain Total _________

__________ Pain or aches in joints __________ Arthritis __________ Stiffness or limitation of movement __________ Pain or aches in muscles __________ Feeling of weakness or tiredness Total _________

__________ Binge eating/drinking __________ Craving certain foods __________ Excessive weight __________ Compulsive eating __________ Water retention __________ Underweight Total _________

__________ Fatigue, sluggishness __________ Apathy, lethargy __________ Hyperactivity __________ Restlessness Total _________

__________ Poor memory __________ Confusion, poor comprehension __________ Poor concentration __________ Poor physical coordination __________ Difficulty in making decisions __________ Stuttering or stammering __________ Slurred speech __________ Learning disabilities Total _________

__________ Mood swings __________ Anxiety, fear, nervousness __________ Anger, irritability, aggressiveness __________ Depression Total _________

__________ Frequent illness __________ Frequent or urgent urination __________ Genital itch or discharge Total _________

Grand Total _________

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

LUNGS

Pg.. 10



757.491.2598



Financial Policy

Vitality! is a cash practice. Payment for services is due as services are rendered. Credit card, cash, and check are accepted forms of payment. We have incorporated several payment options:

1. Pay Per Visit. When services are rendered2. Care Credit. Financing through GE provides you with several interest-free payment plans for simplemonthly payments over 6 or 12 months.3. Prepayment. A prepayment of $1500 entitles you to 10% off all services in the office.

Cancellations Any appointment missed or cancelled with less than 24 hours notice is subject to a missed ap-pointment fee equal to that of the scheduled appointment time.

Insurance 1. Vitality! does not process any form of insurance. If you are a patient of Dr. Lex, following your visit

you will be provided with a sales receipt (superbill) of services rendered which you may personallysubmit to your insurance provider. The superbill has the procedural and diagnostic codes insurancecompanies require for claims.

2. All insurance companies and policies differ, and are in a constant state of flux. Our office is “out-of-network” with most companies. WE DO NOT GUARENTEE ANY FORM OF REIMBURSEMENT ONSUBMITTAL.

3. We do not participate with any state or federal Medicare or Medicaid plan.

Our goal is your health and wellness. Insurance is an incomplete system that can limit the doctor’s abil-ity to spend adequate time with the patient, and provide the best care for each individual.

Signing below indicates that you understand and agree to abide with the Financial Policy of Vitality!

Patient’s Signature: ___________________________________________Date: ____________________ (if patient is a minor, guardians signature)

□ Please check this box if you would like a copy of this document


Pg. 11



757.491.2598




Notification of Privacy Practices Signature Required on Page 2

In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients and have on file a ‘Notice of Privacy Practice’ statement.

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

Janine Lex Chiropractic & Acupuncture LLC (dba Vitality!) is required, by law, to maintain the privacy and con-fidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. Workers’ Compensation We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or lo-cating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Deceased Persons. We may disclose your health information to coroners or medical examiners. Organ Donation. We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

PAGE 1 OF 2

Pg. 12

Notification of Privacy Practices

Public Safety. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Reminders. We may contact you for appointment reminders and rescheduling.Change of Ownership. In the event that Janine Lex Chiropractic & Acupuncture LLC is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information Rights � You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. � You have the right to inspect and copy your health information. � You have a right to request that Janine Lex Chiropractic & Acupuncture LLC amend your protected health information. Please be advised, however, that Janine Lex Chiropractic & Acupuncture LLC is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. � You have a right to receive an accounting of disclosures of your protected health information made by Janine Lex Chiropractic & Acupuncture LLC . � You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices Janine Lex Chiropractic & Acupuncture LLC reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Janine Lex Chiropractic & Acupuncture LLC is required by law to comply with this No-tice.

Janine Lex Chiropractic & Acupuncture LLC is required by law to maintain the privacy of your health informa-tion and to provide you with notice of its legal duties and privacy practices with respect to your health informa-tion.

This notice is effective as of March 11, 2008.

I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Janine Lex Chiropractic & Acupuncture LLC with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice

________________________________________________ Patient’s Name (print)

________________________________________________ ______________ Patient’s Signature Date

________________________________________________ ______________ Authorized Facility Signature Date

PAGE 2 OF 2

Pg. 13



757.491.2598




If we need to acquire records, test results, or x-rays from other health organizations, they are legally required to receive this signed form from us.

This form does not allow us to release your information to any other source.

Authorization for the Release of Information

TO: ________________________________

I, the patient, hereby authorize the release of all medical records to Dr. Janine Lex, and authorize communication with other healthcare practitioners concerning my care. This includes x-rays, MRI’s, and laboratory results.

_________________________________________ _____________________ Patient (or guardian) Signature Date of Birth

_________________________________________ Print Name

_________________________________________ _____________________ Witness Date

Requesting Physician Dr. Janine Lex 3061 Brickhouse Court, Ste 107 Virginia Beach, VA 23452 Ph. 757.491.2598 Fax: 757.493.3980 [email protected]

ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT CONFIDENTIAL / HIPPA-Approved Form

Pg. 14



757.491.2598




We require this form to be signed and on file. Please complete even if you do not receive Medicare benefits.

I, _______________________________, acknowledge that Janine Lex Chiropractic & Acupuncture (dba Vitality! Functional Medicine) has informed me that Medicare will not be billed by this office for any service provided in this office. Dr. Janine Lex is not a Medicare Provider.

I agree that I will not bill Medicare for any of my services provided in this office.

I do / do not receive Medicare benefits. (circle one)

Signed: ____________________________

Date: ______________________________

Witness: ___________________________

2019




757.491.2598



January 29, 2018

Dear Patients,

As many of you know, I had a successful insurance based physical medicine practice for 20 years in Ghent before deciding to switch to a cash-only functional medicine practice.

The decision to go to a cash-only practice was made as the increasing cost of negotiating with insurance companies and supplying information became more and more costly. Around the turn of the century many of my colleagues in Ghent, including many MDs, decided to go into either concierge practices or research. It soon became evident to me it was more cost effective and healthy to step out of the 3rd party payee system. The very nature of insurance is structured specifically to make money for the insurance company and help you during catastrophes. The type of medicine I practice is not catastrophe medicine.

We are willing to help you get reimbursement from your insurance company. Here are my recommendations to make it an efficient process:

1) Be sure to bill your insurance company immediately upon receiving your first superbill.You will have to download their form and fill out your part and then attached a copy of yoursuperbill to the form. Highlight the diagnosis code and procedure code. Make copies ofeverything you send in.

2) When your insurance company responds, let our office know what they request. So that we canstructure your superbills appropriately in the future.

3) We recommend you continue to bill them regularly since they are constantly updatingrequirements.

Your invoice/superbill which you receive each visit has all the information your insurance company needs. You generally need to attach our invoice/superbill to their form. We have the most success with people recovering monies from health savings plans (HSP). I highly recommend seeking outreimbursement through your HSP. We are a physician office and all of our services and supplements are covered.

Our office is a cash based practice. Our accounting is set up this way. We use a regulated accounting software per our accountant. It is difficult to make changes on old super bills and stay within the confines of the law, i.e. taking off cash discounts and changing charges. You may opt to not be given a discount if you believe that will help you recover monies.

If you need help communicating with your insurance company we will do the best we can without overex-tending my already busy staff. For any special documentation that supersedes common practice we bill for staff time at $50/hr.

Thank you for your understanding,

Janine Lex, D.C.

Dr. Janine Lex A functional Medicine Practice Pg_ Other (Yoga, Pilates) _ Avg intensity of...

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Transcript of Dr. Janine Lex A functional Medicine Practice Pg_ Other (Yoga, Pilates) _ Avg intensity of...

Dr. Janine Lex A functional Medicine Practice Pg_____ Other (Yoga, Pilates) _____ Avg intensity of...

Documents

Transcript of Dr. Janine Lex A functional Medicine Practice Pg_____ Other (Yoga, Pilates) _____ Avg intensity of...

Dr. Janine Lex A functional Medicine Practice Pg_ Other (Yoga, Pilates) _ Avg intensity of...

Transcript of Dr. Janine Lex A functional Medicine Practice Pg_ Other (Yoga, Pilates) _ Avg intensity of...