EFTA00314076.pdf

Chairman Dept ot Urology Icahn School or Merlons at Mourn Sinai PH (212) 241.9955 Mount Sinai July 25, 2016 Date: Reason for Today's Visit: __ Dog: Jan. 20, 1953 1 Name: Jeffrey Epstein Age: 63 Past Medical History Hypertension Bleeding Disorder Blood Clots Thyroid Disorder Stroke / Heart Disease Seizure Disorder Enlarged Prostate Heart Murmur Diabetes i i Hemorrhoids/ IBS Anemia Kidney Disease High Cholesterol Hernia Sexual Dysfunction Other: Surgical History 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 00 Children: Noi0 QYes Number: Colon Cancer O0 Smoke: Noe °Yes (lists packs and years) Bladder Cancer • O Alcohol: Nc0 0 Yes (list drinks per week) Heart Disease O0 Caffeine: NoQ ®Tes Dist a per day) Other: O0 Review of Systems Constitutional Significant Changes in Weight YesQ Q No Fevers and Chiils YesQ Q No FOR OFFICE USE ONLY Neese Q No Urologist: Fatigue Persistent Headaches Yes® 0 No Biopsy Date: Visual Problems YesQ 0 No LEFT RIGHT 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 Diarrhea or Constipation king Yes 8 No No IIEF: 6 IPSS: 0 Genitourinary Burning on Uri-Nation Yes Q No PSA I Prostate Volume: Blood in Urine Yes Q No ORE: I Number of Total Past Biopsies: incontinence of Unne Yes() Q No Height: I Weight: I BMI: Musculoskeletal Imaging: 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 EFTA00314076