SPECIAL SURGERY Women's Sports Medicine Center Confidential Medical History July 6 2016 Date Name JeffreyEpstein Age 63 Birthdatel I Tome # Work # Occupation Banker Referred by Dr. Bruce Moskowitz °Right Handed O ft Handed Chief Complaint etisv CiA cp2Alt‘ . C a. abkt(C qc, Date of injury or onset of symptoms Describe the injury or problem r•A>at it c.A411,_,) Where is your pain? Please mark the drawing. _ Have you had any of the following tests or treatments for this problem? (please check) 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? 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 etc 1 EFTA00313707