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
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]
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
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]
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
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]
Medications & Supplements
Please list all current Prescription medications
Name Strength How Many How often / when
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
Please list all over the counter medications
Name Strength How Many How often / when
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
Please list all current Vitamins & supplements
Name Strength How Many How often / when
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________
_______________________________ __________ ___________ _______________________________ 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
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]
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
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]
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
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]
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
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
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
D r . J a n i n e L e x
Pg. 11
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
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
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
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
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
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
D r . J a n i n e L e x
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
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.