Please make sure you submit this form at least 1-2 weeks prior to your scheduled appointment date or your appointment will have to be canceled and rescheduled. Thank you for understanding!

    Basic Information

    Please Select 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.

    Contact Information

    Insurance Information

    Emergency Contact Information

    Medical Questionnaire

    Questions contained in this questionnaire are strictly confidential and will become part of your medical record.

    Basic Medical History

    Childhood Illnesses (Check all that apply)

    Immunizations and Last known Date Received

    Known Medical Problems

    List Past Surgeries

    Date

    Hospital

    Other Care Providers

    Hospitalizations

    Hospital

    Date

    Reason

    Have you ever had a blood transfusion?*

    YesNo

    Lifestyle Questions

    Are you currently dieting?*

    YesNo

    If yes, are you on a physician-prescribed medical diet?

    YesNo

    Salt Intake*

    LowMediumHigh

    Fat Intake*

    LowMediumHigh

    Caffeine Intake (# of cups per day)*

    Do you drink alcohol?*

    YesNo

    Are you concerned about the amount of alcohol you drink?

    YesNo

    Have you ever experienced blackouts?

    YesNo

    Are you prone to binge drinking?

    YesNo

    Do you use tobacco?*

    YesNo

    Family Medical History

    Medications

    Please list your perscription medications

    Name of Drug

    Strength

    Frequency Taken

    Vitamin Supplements and OTC Medications

    Name of Drug

    Strength

    Frequency Taken

    Please list any allergies/intolerances to any medications

    Name of Drug

    Reaction You Had

    Health Habbits

    Please select your level of exercise

    Sedentary (No Exercise)Mild Exercise (Climb Stairs, Walk Several Blocks, Play a Round of Golf)Occasional Vigorous Exercise (Duration of at least 30 minutes < 4x per weekRegular Vigorous Exercise (Duration of at least 30 minutes >= 4x per week

    Patient Consent for Release of Private Health Information

    As a patient of Jorge L. Hernandez, Waguih El Masry, Sean Nonnemaker, Leslie Gomez, and Lisa Shannon, I give the following consent for the staff of this practice to leave any information with the family members of my household or on an answering machine. (Please indicate your consent by checking the boxes below:

    I give the practice permission to share my personal health information with the following person:

    By typing your name above, you are hereby signing this form and granting permission for us to store and use your medical information for the purposes of treating you here at Best Coast Internal Medicine. We promise that this information is 100% confidential and will be submitted to us safely and securely.

    If the form will not submit, please review and ensure that you have filled out every required field marked with a red asterisk (*) and try again.