EFTA00314076.pdf

Chairman Dept ot Urology Icahn School or Merlons at Mourn Sinai PH (212) 241.9955 Mount Sinai Date: Name: July 25, 2016 Jeffrey Epstein Past Medical History 1 Hypertension Heart Murmur Anemia Other: Surgical History Reason for Today's Visit: Dog: Jan. 20, 1953 Age: 63 Bleeding Disorder Blood Clots __ Thyroid Disorder Stroke / Heart Disease Diabetes Seizure Disorder i i Hemorrhoids/ IBS Enlarged Prostate Kidney Disease High Cholesterol Hernia Sexual Dysfunction Medication Name and Dosage (including supplements) Allergic to any meds? NoQQYes If yes, list medication & reaction: Social History Occupation: Banker Family History Yes No Family Member Single Marital Status: Prostate Cancer Children: Noi0 QYes Number: Colon Cancer Smoke: Noe °Yes (lists packs and years) Bladder Cancer Alcohol: Nc0 0 Yes (list drinks per week) Heart Disease Caffeine: NoQ ®Tes Dist a per day) Other: Review of Systems Constitutional Significant Changes in Weight YesQ Q No Fevers and Chiils YesQ Q No Fatigue Neese Q No Persistent Headaches Yes® 0 No Visual Problems YesQ 0 No Cardiovascular Shortness of Breath YesQ 0 No Chest Pan YesQ Q No Palpitations YeS0 Q No Respiratory Cough / Wheezing ',Peso Q No Gastrointestinal Nausea and Vomiting king 8 No Diarrhea or Constipation Yes No Genitourinary Burning on Uri-Nation Yes Q No Blood in Urine Yes Q No incontinence of Unne Yes() Q No Musculoskeletal Muscle Weakness Yes() 0 No Skin Skin rash or Union YesQ 0 No Neurological Seizures YesQ Q No Numbness or Tingling YesQ Q No Pave:Marne Depressmon arialeY YesQ 10 No Hematology Easy Bruising YesQ Q No Unusual Bleeding YesQ Q No 00 O 0 • O O 0 O 0 FOR OFFICE USE ONLY Urologist: Biopsy Date: LEFT RIGHT IIEF: 6 IPSS: 0 PSA I Prostate Volume: ORE: I Number of Total Past Biopsies: Height: I Weight: I BMI: Imaging: EFTA00314076