Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
DATE OF BIRTH: ________________________
ADDRESS_____________________________________________________:
CITY: ________________________ STATE:____ ZIP____________________
E-MAIL: ______________________________________________________
HOW DID YOU HEAR ABOUT DR. EPSTEIN?________________________
HOME TEL: ______________CELL: ___________ WORK: ______________ ___
PHARMACY NAME & TELEPHONE:____________________________________
MARITAL STATUS: ________ETHNICITY/RACE:__________________________
EMAIL: __________________SOCIAL SECURITY_________________________
EMERGENCY CONTACT:__________________TELEPHONE:_______________
PATIENT SIGNATURE:________________________DATE:________________
Palisades Professional Center, 2 Medical Park Drive, Suite 4
West Nyack, NY 10994 845-358-8878
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Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
PATIENT MEDICAL HISTORY [Circle all that Apply]
Anxiety
Arthritis Artificial joints Asthma
Atrial fibrillation
BPH
Bone Marrow Transplant
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism Leukemia
Lung Cancer
Lymphoma Pacemaker
Prostate Cancer
Radiation Treatment Seizures
Stroke
Valve Replacement
Other: ______________________________________________________
PAST SURGICAL HISTORY [Circle all that apply]
Kidney Biopsy
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP
Skin Biopsy
Basal Cell Cancer Surgery
Squamous Cell Carcinoma Surgery
Melanoma Surgery
Spleen Removed
Testicles Removed (Right, Left,
Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
None
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
PTCA
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Knee (Right, Left,
Bilateral)
Joint Replacement, Hip (Right, Left,
Bilateral)
(Joint Replacement within last 2
years)
Other:_________________________________________________
2
Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
SKIN DISEASE HISTORY [Circle all that apply]
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
None
Other:_________________________________________________
Do you wear Sunscr een? Yes No
Do you tan in a tanning salon?
If yes, what SPF?____
Yes No
Do you have a family history of Melanoma?
Yes No
If yes, which relative(s)? _________________________________________________
Medications: [Please enter all current medications] ____________________________
________________________________________________________________________
Allergies: [Please list all allergies] ___________________________________________
________________________________________________________________________
SOCIAL HISTORY [Circle all that apply]
Has never smoked
Currently Smokes - daily
Has smoked in the past
Alcohol—None
Alcohol—less than 1 drink daily
Alcohol--1-2 drinks daily
Alcohol 3+ drinks daily
IV Drug Use
No IV drug use
Not sexually active
Sexually active with one partner
Sexually active with more than one
partner
Same sex partner
Patient feels safe at home
Patient feels unsafe at home
Mother: Alive/Deceased at age_ __medical problems ___________________
Father: Alive/Deceased at age _ __medical problems ___________________
Siblings: Sisters ____________ medical problems ______________________
Brothers __________________ medical problems ______________________
Children: Daughters _____ Sons _____
3
Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
REVIEW OF SYMPTOMS: ARE YOU EXPERIENCING ANY OF THE FOLLOWING
[PLEASE CHECK YES OR NO]
SYMPTOMS
YES
New or changing growth,(enlarging, bleeding, sensitive,
coloration, shape)
Veins enlarging, uncomfortable
problems with scarring (hypertrophic or keloid)
Easy bruising, problems with bleeding
rash
Hair changes either loss of hair or new unwanted hair
growth
Nail changes thickening, brittle,
redness or pain in skin around nail
Photosensitivity
anxiety
depression
blurry vision
Vision decreased at night
headaches
Yeast Infection with antibiotics
antibiotics
immunosuppression
Allergies seasonal (hay fever) or food allergies
fever or chills
night sweats
sore throat
cough
shortness of breath
wheezing
Cold or Heat intolerance,
thyroid problems
unintentional weight loss
Increase in thirst
Urinary frequency increased
abdominal pain
Gastro-Esophagel Intestinal Reflux (GERD)
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NO
Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
SYMPTOMS
YES
NO
GI discomfort with antibiotics
Bloody stool
Bloody urine
Joint aches
Muscle weakness
fatigue
Chest pain
Mammogram done as recommended by primary care doctor
Colonoscopy
Other?
Other?
ALERTS: Check all that apply
o Allergy to latex rubber
o Allergy to Penicillin or other antibiotics
o Allergy to Lidocaine, Prilocaine, Betacaine or other local anesthesia
o Artificial joints within past two years
o Pacemaker or defibrillator
o Pre-medication needed prior to procedures
o Blood thinners, aspirin, Coumadin, NSAIDS (Advil)
o Rapid heartbeat with epinephrine
o Pregnancy or planning a pregnancy
o Infectious Hepatitis (C or B)
o Artificial Heart Valve
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Wendy A. Epstein, M.D., F.A.A.D
PATIENT NAME______________________________________ DATE _________
Acknowledgement of Notice of Privacy Practices
I have been presented with a copy of the Notice of Privacy Practices for the office of
Wendy A. Epstein, M.D., detailing how my information may be used and disclosed as
permitted under federal and state law.
THE FOLLOWING PEOPLE ARE AUTHORIZED TO DISCUSS AND RECEIVE MY PERSONAL
HEALTH INFORMATION:
NAME
RELATIONSHIP
________________________________
_____________________________
________________________________
_____________________________
________________________________
_____________________________
________________________________
_____________________________
Signed: _______________________________________ Date: _____________
If not signed by patient, please indicate relationship to patient (e.g., mother) and patient’s name.
Patient:_____________________________________________ Relationship:____________________
Palisades Professional Center, 2 Medical Park Drive, Suite 4
West Nyack, NY 10994 (845-358-8878)
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