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.