Patient Information Choose Your Doctor Dr. Jorge L. Hernandez, M.D.Dr. Waguih El Masry, M.D.Dr. Sean Nonnemaker, D.O.Dr. Leslie Gomez, D.O.Dr. Lisa Shannon, D.O.Dr. Juliana Dale, DO Name:* DOB:* Reason for Visit:* Preferred Pharmacy:* Do you have any allergies?* Medications List of medications CURRENTLY being taken (prescribed, over the counter, and vitamins) Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Name: Strength: How Often: Medical History Mark ALL that apply. ADD ADHD Anemia Angina Anxiety Arthritis Asthma Atrial Fibrillation Bipolar Disorder Bladder Cancer Bowel Problems Breast Cancer Breathing Difficulties Cancer Type: Cirrhosis Colon Cancer COPD Crohn's Disease Dementia Depression Diabetes Diverticulitis Eczema Emphysema GERD Gout Heart Attack Heart Disease Heart Murmur Hepatitis (A, B, or C) High Blood Pressure High Cholesterol Liver Problems Lung Cancer Migraines Osteoarthritis Pancreatic Cancer Parkinson’s Pneumonia Polymyalgia Prostate Cancer Psoriasis Psychiatric Problems Pulmonary Embolism Rectal Cancer Rheumatoid Arthritis Rosacea Seizure Disorder Sickle Cell Sjogren Syndrome Stroke/CVA Other Type: Surgical Procedures Mark ALL that apply. ACL Surgery/Reconstruction Adenoids Removed Appendix Removal Back Surgery Gallbladder Removed Hip Replacement Knee Replacement Hysterectomy Splenectomy Tonsils Removed Breast Augmentation Cardiac Bypass Surgery Cardiac Catheterization Cataract Surgery Colon resection Lumpectomy Lymph Node Biopsy Mastectomy Tubal Ligation Vasectomy Total Joint Replacement Colostomy/Reversal C_Section D&C (Dilation & Curettage) Defibrillator Implant Pacemaker PTCA (Angloplasty) Shoulder Surgery Other Type: Women's Health Last Menstrual Period: NormalAbnormal PAP/Pelvic Exam: NormalAbnormal Last Mammogram: NormalAbnormal Bone Density Exam: NormalAbnormal # of Pregnancies: # of Deliveries: # of Miscarriages: # of Abortions: Health Maintenance Physical Exam/Wellness Visit: NormalAbnormal Cholesterol: NormalAbnormal Colonoscopy: NormalAbnormal EGD: NormalAbnormal Prostate/PSA: NormalAbnormal Stress Test/Nuclear Stress Test: NormalAbnormal Immunizations Hepatitis A #1 #2 Hepatitis B #1 #2 #3 Gardasil (HPV) #1 #2 #3 COVID Type: Dates: Influenza Pneumonia Tetanus Shingrix (Shingles) TB Skin Test Chicken Pox Social History Are you a smoker? NeverFormerCurrent If YES, mark all that apply: Cigarettes Cigars Chewing/Dipping Tobacco Electronic Cigarettes How much per day? How many years? Quit Date: Do you drink alcohol? NeverDailySocial Estimated Daily Consumption: Are you sexually active? YesNo Are you using a form of birth control? YesNo If YES, what type? Have you ever had an STD? YesNo If YES, what type? Street Drug Use: NeverFormerlyCurrently If YES, what type? Do you feel safe at home? YesNo Do you have a living will? YesNo Do you have a durable Power of Attorney for healthcare? YesNo Family History Are you adopted? YesNoUnknown Mother Living? YesNo Age of Death: Cause of Death: Father Living? YesNo Age of Death: Cause of Death: Please list any serious medical history that runs in your family Mother Father Sibling Maternal Grandparent Paternal Grandparent Other Care Providers Provider List (Physician/Practice Name) Cardiologist: Gastroenterologist: General Surgeon: Neurologist: OBGYN: Primary Care: Urologist: Other: Hospitalizations Hospital Admission/ER Visit? Year Diagnosis Privacy NOTICE OF PRIVACY PRACTICES A copy of Facility's HIPAA Notice of Privacy Practices is posted in the main lobby and available for me to read in its entirety. The HIPAA Notice of Privacy Practices contains information on the uses and disclosures of my protected health information (PHI). DISCLOSURE OF PROTECTED HEALTH INFORMATION AND EMERGENCY CONTACT I authorize Facility to communicate with the following individuals about my medical condition, diagnosis, treatment, appointments (past and future), and financial obligation. l understand medical information may be withheld from individuals, including family members unless l List them by name below. Name: Relationship: Name: Relationship: I authorize Facility to leave voicemail or answering machine messages regarding test results or other healthcare related concerns at my home or cell phone number. Yes No EMERGENCY CONTACT INFO Emergency Contact: Phone Number: Relationship: Email Address: FINANCIAL POLICY AND AUTHORIZATION FOR ASSIGNMENT OF BENEFITS Facility strives to make our financial policy, Insurance filing, and billing process for our patients as simple as possible. It is your responsibility to make sure we have your correct insurance information and also your responsibility to know your co-pay, co-insurance amount, and deductible. For Self-Pay patients, payment must be made at the time of service, and a 5O% discount is offered to those patients. Patients will be assessed a $30 fee for checks returned due to Insufficient Funds. Statements are mailed out each month. Please contact our Central Billing Office for questions or concerns regarding your balance. Facility will submit claims to my primary and secondary insurance directly for their services. I authorize payment directly to Facility of any insurance benefits otherwise payable to me. Charges deemed as non-covered by insurance company are the responsibility of the patient except as required by law for State and Federal reimbursement programs. I authorize Facility to release or receive any information necessary to expedite insurance claims. GENERAL CONSENT FOR EXAMINATION AND TREATMENT I hereby consent and authorize Facility to perform medical examinations and provide routine medical care for all my visits. This may include routine diagnostic and laboratory procedures and tests, medication administration, and other routine care for which a specific informed consent form will not be signed by me. This consent includes consent and authorization to photograph or otherwise take images of me and/or parts of my body for purposes of identification, diagnosis, treatment, payment, and healthcare operations of Facility. Any photographs or other images taken will become part of my medical record. Facility will not use such photographs or images for any other purposes without my specific written consent. l understand that certain procedures will require specific informed consent and that Facility will provide me with information and forms prior to such procedures. I grant Facility consent to submit immunizations administered to State Immunization Registry, and to view and/or import all medication history prescribed within the last two years. I authorize Facility to search for and access my records through a Health Information Exchange (HIE) for purposes of medical treatment. I have the right to opt-out at any time by notifying Facility. Patient's Name:* Patient's Representative: (if patient is unable to sign) Typing your name above constitutes a legal signature. Demographics Patient Information Last Name:* First Name:* Middle Name:* Suffix: Social Security Number:* Date of Birth:* Primary Care Physician: Gender MaleFemale Marital Status DivorcedMarriedSeparatedSingleWidowedOther Preferred Language EnglishSpanish Race AsianBlackWhiteOther Ethnicity HispanicNot Hispanic Mailing Address: Apartment/Lot: City/State: Zip Code: Phone Numbers: Home: Mobile: Work: Email Address: How did you hear about us? Referring Physician: Responsible Party Responsible Party is the Same as Patient Last Name: First Name: Date of Birth: Relationship to Patient: Gender MaleFemale Mailing Address: Apartment/Lot: City/State: Zip Code: Phone Numbers: Home: Mobile: Work: Employer Information Employer: Address: City/State: Zip Code: Emergency Contact Emergency Contact is the Same as Responsible Party Last Name: First Name: Date of Birth: Relationship to Patient: Gender MaleFemale Mailing Address: Apartment/Lot: City/State: Zip Code: Phone Numbers: Home: Mobile: Work: Guardian Contact Guardian is the Same as Responsible Party Guardian is the Same as Emergency Contact Last Name: First Name: Date of Birth: Relationship to Patient: Gender MaleFemale Mailing Address: Apartent/Lot: City/State: Zip Code: Phone Numbers: Home: Mobile: Work: Mental Health Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Feeling down, depressed, or hopeless Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Trouble falling or staying asleep, or sleeping too much Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Feeling tired or having little energy Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Poor appetite or overeating Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Feeling bad about yourself or that you are a failure or have let yourself or your family down Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Trouble concentrating on things such as reading the newspaper or watching television. Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Moving or speaking so slowly that people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. Not at AllSeveral DaysMore Than Half The DaysNearly Every Day Thoughts that you would be better off dead or of hurting yourself in some way. Not at AllSeveral DaysMore Than Half The DaysNearly Every Day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at homes, or get along with other people. Not difficult at allSomewhat difficultVery difficultExtremely difficult Insurance Information Check if Self Pay Check if Same as Responsible Party Subscriber Name: Date of Birth: Relationship to Patient: Gender MaleFemale Primary Insurance Company: Begin Date: Insurance Mailing Address: City/State: Zip: Subscriber #: Group #: Check if Same as Responsible Party Subscriber Name: Date of Birth: Relationship to Patient: Gender MaleFemale Secondary Insurance Company: Begin Date: Insurance Mailing Address: City/State: Zip: Subscriber #: Group #: Patient/Guardian Signature Date Typing your name above constitutes a legal signature. Click here to view and read the Best Coast Internal Medicine Privacy Notice I have read and understand the Best Coast Internal Medicine Privacy Notice Δ
