EFTA00313707.pdf

Date July 6 2016 SPECIAL SURGERY Women's Sports Medicine Center Confidential Medical History Name JeffreyEpstein Age 63 Birthdatel I Tome # Work # Referred by Dr. Bruce Moskowitz Occupation Banker °Right Handed O ft Handed Chief Complaint etisv CiA a. cp2Alt‘ . Cabkt(Cqc, Date of injury or onset of symptoms Describe the injury or problem r•A>atit c.A411,_,) Where is your pain? Please mark the drawing. Rate Your Pain: Cr= No pain .) 10 = Extreme pain I. Right now 2. At best 3. At worst 4. What makes it better? 5. What makes it worse? _ Have you had any of the following tests or treatments for this problem? (please check) Tests Date(s) of your tests Treatments (If so, describe whether they helped.) O X-RAY O MEDICATIONS a MID ID - 4- AO1S ❑truec-noNs o Cr SCAN O SURGERY O MYEWGRAM O PHYSICAL THERAPY O BONE SCAN O OTHER TESTS AND TREATMENTS POOP I etc1 EFTA00313707