CANCER CENTER FOR HEALING MEDICAL QUESTIONNAIRE Please fill out the medical questionnaire below. Once completed, please save and return as an attachment by email to . Once Dana receives the information she will contact you to arrange a consultation with one of our Cancer Team Doctors. After the consult we will customize a treatment plan. INSURANCE INFORMATION: Please provide Cancer Center For Healing with a front and back copy of your insurance card so we can verify coverage prior to your consultation. NOTE•: In lieu of medical records, please send all pertinent scan reports (MRI, Ultrasounds, PET) and all pertinent labs taken in the last 3 months to We do not accept records on CDs, please provide us with a word or PDF document. Patient Name: Jeffrey Epstein DOB: Jan. 20, 1953 Age: 63 Sex: Male Home Phone: Cell Phone: Who do we contact to set up the consultation (name & hone number): Lesley- Email: Home Address: Street, City, State & Zip 9 East 71s, Street New York, New York 10021 Date of Cancer Diagnosis: Na Type of Cancer (Pathology Diagnosis): N/A 6 Hughes, Suite 12081 Irvine, CAI 92618 www.cancercenterforhealing.com EFTA00295979

CANCER CENTER FOR HEALING Cancer Stage: N/A Have you received Chemo? What dates did you receive treatment?: N/A Have you received Radiation? What dates did you receive treatment?: N/A Have you had surgery to treat your cancer? What date(s) did you have the surgery(s) on? N/A Any Complications from previous treatments?: N/A Date of last bloodwork: N/A Date of last PET Scan: N/A Therapies currently receiving for psychological/emotional wellbeing: N/A Father's medical history: Bladder 6 Hughes, Suite 120B I Irvine, CA I 92618 www.cancercenterforhealing.com EFTA00295980

CANCER CENTER FOR HEALING Mothers medical history: N/A Family medical history: N/A Do you have a history of smoking or drinking? no Have you ever been hospitalized? What was your diagnosis? What dates were you in the hospital? N/A What is your dental history? Any major procedures N/A Are you in pain?: N/A Specify type of pain on a scale from 1 to 10: N/A Pain medication type and dosage: N/A When do you plan to start treatment with Cancer Center For Healing?: N/A How did you hear about Cancer Friend who is a doctor Center For Healing?: 6 Hu hes, Suite 120B Irvine, CA 92618 www.cancercenterforhealing.com EFTA00295981

CANCER CENTER FOR HEALING Additional information we should N/A know: 6 Hu hes, Suite 120B Irvine CA 92618 www.cancercenterforhealing.com EFTA00295982