Chairman Dept of Urology Icahn School of Medicine at Mount Sinai , BD Ph: (212) 241-9955 July 25, 2016 ite: Reason for Today's Visit: Name: efrey Epstein DOB: Ja. 20, 1958 Age: 83 Past Medical History Hypertension Disorder Clots id Disorder Stroke / Heart Disease art Murmur izure Disorder jemorrhoids / IBS Enlarged Prostate i idney Disease igh Cholesterol lernia Sexual Dysfunction Surgical History Medication Name and Dosage (including supplements) Allergic to any meds? NoC)OYes If yes, list medication & reaction: Social History Occupation: Banker Family History Yes No Family Member Marital Status: Single Prostate Cancer O@ Children: No@OvYes Number: Colon Cancer Oo @ Smoke: No@Oves (list # packs and years) Bladder Cancer (S) oO Alcohol: No@®Oves (list drinks per week) Heart Disease O e Caffeine: NoO @yes (list #perday) Other: O e Review of Systems joxe) Significant Changes in Weight Yes No fence ond Cala tO Q ro FOR OFFICE USE ONLY Fatigue Yes No Urologist: Persistent Headaches Yes@ O No Biopsy Date: Visual Problems Yes@ O No LEFT RIGHT Cardiovascular Shortness of Breath vesQ Ono Chest Pain YesQ Ono Palpitations YesOQ ONo Respiratory Cough / Wheezing yesO Ono Ceaeisleaneala Nausea and Vomiting Yes No Genitourinary . Burning on Urination Yes: No PSA: _s,:~ Prostate Volume: Blood in Urine ee an ORE: Number of Total Past Biopsies: Incontinence of Urine YesO Ono Height: Weight: | BMI: Musculoskeletal imaging: Muscle Weakness Yes ONo Skin Skin rash or Lesion YesO ONo Neurological Seizures yesO Oo Numbness or Tingling YesO Ono Psychiatric Depression / Anxiety YesO ONo Hematology —.. bes EFTA00314076