Chairman Dept ot Urology
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
1Hypertension
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 ii 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
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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