Jeffrey Epstein's intake medical records at MCC New York, July 2019

EFTA00033830¶

Bureau of Prisons Health Services See Amendment¶

Inmate Name: Date of Birth:	EPSTEIN, JEFFREY EDWARD 01/20/1953 Encounter Date: 07/14/2019 17:36	Sex:	M	Reg #: Race: Facility:	76318-054 WHITE NYM

Amendment made to this note by on 07114/2019 18:11.¶

&mftwoflhiumis.NYM¶

Bureau of Prisons Health Services Clinical Encounter - Administrative Note¶

Inmate Name: Date of Birth: Note Date:	EPSTEIN, JEFFREY EDWARD 01/20/1953 07/12/2019 09:06	Sex: Provider:		Reg #: Facility: Unit:	76318-054 NYM 205
Administrative Notes:	Admin Note - Orders encounter performed at Health Services. ADMINISTRATIVE NOTE 1	Provider:
	PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION.
New Medication Orders:
B.24	Medication		Order Date	Prescriber Order
	Docusate Sodium Capsule		07/12/2019 09:06		TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s)
	Indication: Constipation, unspecified
	Discontinued Medication Orders:
Bit#	Medication.		Order Data	prescriber Order
121757-NYM	Bisacodyl E.C. 5 MG TAB		07/12/2019 09:06	days	Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10
	Discontinue Type:	When Pharmacy Processes
	Discontinue Reason:discontinue
	Indication:
Copay Required: No TelephoneNerbal Order:	No	Cosign Required: No
Completed by	on 07/12/2019 09:10

Generated 07/12/2019 09:10 by Bureau of Prisons • NYM¶

Bureau of Prisons Health Services Clinical Encounter - Administrative Note¶

Inmate Name: Date of Birth: Note Date:	EPSTEIN, JEFFREY EDWARD 01/20/1953 07/07/2019 00:17	Provider: Sex:		Reg #: Facility: Unit:	76318-054 NYM E06
Administrative Notes:	Cosign Note - Intake Cosign encounter performed at Health Services.
	ADMINISTRATIVE NOTE 1 MED CL:1 NO CCC APPT.	Provider:
	Discontinued Laboratory Requests:
Details (CMP)	Lab Tests-H-Hemoglobin A1C Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information:	Frequency One Time		Due Date 08/05/2019 00:00	Priority Routine
	66 y/o male, elevated BP
	Labs requested to be reviewed by:
New Laboratory Requests:
Details Lab Tests-H-HIV 1/2 Lab Tests-R-RPR	Chronic Care Clinics-Diabetic-CBC w/diff Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-Hemoglobin A1C Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders:	Freauency One Time		DUG Date 07/25/2019 00:00	Priority Routine
Details		Frequency	End Date	Due Date	Priority
General Radiology-Chest-2 Views		One Time		07/25/2019	Routine
	Specific reason(s) for request (Complaints and findings):
	66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR.
Copay Required: No		Cosign Required: No
	TelephoneNerbal Order: No
Completed by		on 07/07/2019 00:30

Generated 07/07/2019 00:30 by¶

CONFIDENTIAL SDNY_00009427¶

Bureau of Prisons Health Services History & Physical¶

Inmate Name: Date of Birth:	EPSTEIN, JEFFREY EDWARD 01/20/1953 Encounter Date: 07/09/2019 12:35

Seizures:		Denied
Diabetes:		Denied
Cardiovascular:		Denied
CVA:		Denied
Hypertension:		Denied
Respiratory:		Denied
Sickle Cell Anemia:		Denied
Carcinoma/Lymphoma:		Denied
Allergies:		Denied
Tuberculosis:
	Hx of Previous Disease: No
	Blood-tinged Sputum: No
Night Sweats: No
Weight Loss: No
Fever: No
Cough:No
Comments:
	Infectious Disease Risk Factors:
IV Drug Use: No
IV Drug Use Needles:
	Sexual Partner IV Drug Use: No
	Sexual Partner IV Drug Use Needles:
	Female Sexual Partners (Last 5 Yrs): 10+
	Male Sexual Partners (Last 5 Yrs): 0
Condom Use: Sometimes
	Sexual Contact With HIV+ Individual: No
	Blood Product Transfusion: No
Travel Outside US: Yes
Tattoos: No
Comments: Born in US	High school diploma Banker Traveled to Pans x 3 weeks up until arrest
	No tattoos

Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 1 of 13¶

CONFIDENTIAL SDNY_00009428¶

Inmate Name: Date of Birth:	EPSTEIN, JEFFREY EDWARD 01/20/1953 Encounter Date: 07/09/2019 12:35
HIV History:
When Tested:		2019
Test Result:		Negative
When Diagnosed AIDS:
Last CD4:
Comments:
Hepatitis:		Denied
Other Infectious Diseases:
Syphilis:		No
	Syphilis Last Treatment:	N/A
Genital Warts:		No
Chlamydia:		Yes
Gonorrhea:		No
Herpes:		No
Chicken Pox:		Yes
Other:		No
	Comments: Chlamydia in 2015, treated Chicken pox in childhood
Abuse History: Denied
Physical: No
Emotional: No
Sexual: No Comments: Denies

Inmate Name:	EPSTEIN. JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:		Facility:	NYM
	Encounter Date: 07/09/2019 12:35	Provider:		Unit:	H01

Mental Health:¶

Level of Consciousness: Alert and Oriented¶

Psychomotor Activity: Normal¶

General Appearance: Normal¶

Behavior: Cooperative¶

Mood: Appropriate to Content¶

Thought Process: Goal Directed¶

Thought Content: Normal¶

Hx of Mental Health Treatment: None¶

Hx of Head Injury: None¶

Current Mental Health Treatment: No¶

Current Mental Health Complaint: No¶

Hx of Loss of Consciousness: No¶

Hx of Hearing Voices: No Past History of Suicide Attempt: No

Current Suicide Ideation: No¶

Suicide Prevention Initiated:No¶

Comments:¶

Substance Use History: Denied¶

Current Painful Condition: Denied¶

Other Health Issues:¶

Current Medical Conditions:¶

Other Current Treatments:¶

Pregnant: N/A¶

Dental Condition: Denied¶

Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Page 3 of 13¶

Inmate Name:	EPSTEIN, JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	1.1/HITS	Facility:	NYM
	Encounter Date: 07/09/2019 12:35	Provider:		Unit	H01

Observations:¶

Draining Skin Lesions: No¶

Signs of Lice: No¶

Signs of Scabies: No¶

Signs of Recent Trauma: No¶

Recent Tattoos: No¶

Needle Marks: No¶

Signs of Rash: No¶

Open Sores: No¶

Wounds: No¶

Body Deformities: No¶

Tremors: No¶

Sweating: No¶

Comments:¶

Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Pardo( 13¶

CONFIDENTIAL SDNY_00009431¶

EPSTEIN, JEFFREY EDWARD Inmate Name: 01/20/1953 Date of Birth: Encounter Date: 07/09/2019 12:35	Sex: Provider:		Race: WHITE		Reg #: Facility: Unit:	76318-054 NYM H01
-------------------------------------------------------------------------------------------------------------	-------------------	—	-------------	—	------------------------------	-------------------------	—

Immunizations:¶

Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered¶

Documented Date: 07/09/2019 12:51 EST¶

Immunization Date:¶

Provider:¶

Location:¶

Drug Mfg:¶

Lot Number:¶

Dosage:¶

Route:¶

Exp Dt:¶

Comments:¶

Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered¶

Documented Date: 07/09/2019 12:51 EST¶

Immunization Date:¶

Provider:¶

Location:¶

Drug Mfg:¶

Lot Number¶

Dosage:¶

Route:¶

Exp Dt:¶

Comments:¶

Smallpox Series Administration: History Unknown, Not Administered¶

Documented Date: 07/09/2019 12:51 EST¶

Immunization Date:¶

Provider:¶

Location:¶

Drug Mfg:¶

Lot Number:¶

Dosage:¶

Route:¶

Exp Dt:¶

Comments:¶

Tetanus Administration: History Unknown, Not Administered¶

Documented Date: 07/09/2019 12:51 EST¶

Generated 07/09f2019 13:03 by Bureau of Prisons - NYM Page 5 of 13¶

CONFIDENTIAL SDNY_00009432¶

Inmate Name:	EPSTEIN, JEFFREY EDWARD			ITE	Reg #:	76318-054 NYM
Date of Birth:	07/09/2019 Encounter Date: 07/09/2019 12:35	Sex: Provider.	•		Facility: Unit:	H01

	Immunization Date:
	Provider:
	Location:
	Drug Mfg:
	Lot Number:
	Dosage:
	Route:
	Exp Dt:
	Comments:
					Varicella Series Administration: History Unknown, Not Administered
	Documented Date: 07/09/2019 12:51 EST
	Immunization Date:
	Provider:
	Location:
	Drug Mfg:
	Lot Number:
	Dosage:
	Route:
	Exp Dt:
	Comments:
Temperature:
pate		Time	Fahrenheit	Celsius	Location	provider
	07/09/2019	12:49 NYM	97.3		36.3 Oral
Pulse:
DAM	Time		Rate Per Minute		Location	Rhythm	Provider
	07/09/2019 12:49			82	Via Machine	Regular
Respirations: Date		Time		Rate Per Minute	Provider
	07/09/2019	12:49 NYM			16
Blood Pressure:
DAM	Time		Yarn	Location	Position	Cuff Slut	Provider
	07/09/2019 12:49 NYM 117/66			Right Arm	Sitting	Adult-regular
SaO2:
Data		Time	Valuee4). Air		Provider
	07/09/2019	12:49 NYM		97 Room Air
Height: DatS	lima		Inches	fa	Provider
	07/09/2019 12:49 NYM		70.0	177.8
	Generated 07,09/2019 13:03 by				Bureau of Prisons • NYM			Page a of 13

CONFIDENTIAL SDNY_00009433¶

Inmate Name: Date of Birth: Encounter Date: 07/09/2019 12:35	EPSTEIN, JEFFREY EDWARD 01/20/1953		Sex:	Provider:	Race: WHITE	Reg #: Facility: Unit:	76318-054 NYM H01
Date Weight: Mt	Time Int	inches Lbs.	Cm	Provider hg Waist Circum.	Provider
07/09/2019	12:49 NYM	194.4	88.2
Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied
General Social History:
Foreign Travel: Born in USA: Country of Birth: USA	Yes
Patient Education Assessments:
Date 07/09/2019	Ed Yrs Occupation 12 Banker		Learns Best By	Speaking/Listening English	Primary Language Barriers to Education	None
Family History - Father:
Age at Death: 74 Significant Illnesses: Diabetes Heart Disease	Cause of Death: Diabetes complications
Comments:
Family History - Mother:
Age at Death: 81 Significant Illnesses: Heart Disease Comments: Family History - Sibling:	Cause of Death: Kidney Failure
Number of Siblings: 1 Significant Illnesses:
Comments: Past Hospitalization:
Reason				Location		When
	Acute Appendicitis Complications: None Comments:			Mount Sinai Hospital		1990
Head:
Normal: Yes
Comments:
Generated 07/09/2019 13:03 by				Bureau of Prisons NYM			Page 7 of 13

CONFIDENTIAL SDNY_00009434¶

Inmate Name: Date of Birth:	EPSTEIN, JEFFREY EDWARD 01/20/1953 Encounter Date: 07/09/2019 12:35		Sex: Provider:	Race. WHITE	Reg #: Facility: Unit:	76318-054 NYM H01
Eyes:
EOMI: Yes lcterus:No Pupils PERRLA: Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Eyes Comments:	Conjunctival Inflammation: No Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No
Vision Screen 07/09/2019 12:52 With Corrective Blindness:
	Distance Vision: OD: 100	OS: 70	OU:	OD:	OS	OU:
Near Vision:	OD:	OS:	OU:	OD:	OS:	OU:
lshihara Color Test:
Tonometry:	L: R:
Comments: Needs evaluation with optometrist.
Ears:
Right Ear: Canal patent
	Left Ear: Canal patent
Ears Comments:
Nose:
Nares Patent: Yes
Septum Midline:Yes
Septum Intact: Yes
Drainage/Discharge:No Polyps: No
Nose Comments:

Generated 07/09/2019 13:03 by¶

Inmate Name:	EPSTEIN, JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:		Facility:	NYM
	Encounter Date: 07/09/201912:35	Provider:		Unit:	H01

Mouth¶

Lesions:No¶

Oral/Buccal Mucosa:Yes¶

Gums Normal: Yes¶

Tonsils Present:Yes¶

Tonsils Normal: Yes¶

Pharynx: Normal Color¶

Teeth Poor Dentition: No¶

Teeth Count:Mostly Present¶

Dentures:No¶

Mouth Comments:¶

Cranial Nerves:¶

Intact Yes¶

Cranial Nerves Comments:¶

Neck:¶

Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Normal Size Comments:¶

Breasts:¶

Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction: No Instructions for Self Breast Exam Given: No Comments:¶

Generated 07/092019 13:03 by Bureau of Prisons - NYM Page 9 of 13¶

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Jeffrey Epstein's intake medical records at MCC New York, July 2019

Bureau of Prisons Health Services See Amendment¶

Bureau of Prisons Health Services Clinical Encounter - Administrative Note¶

Bureau of Prisons Health Services Clinical Encounter - Administrative Note¶

CONFIDENTIAL SDNY_00009427¶

Bureau of Prisons Health Services History & Physical¶

Mental Health:¶

Observations:¶

CONFIDENTIAL SDNY_00009431¶

Immunizations:¶

CONFIDENTIAL SDNY_00009432¶

CONFIDENTIAL SDNY_00009434¶

Mouth¶

Cranial Nerves:¶

Neck:¶

Breasts:¶

CONFIDENTIAL SDNY_00009436¶

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