EFTA00073878

Inmate Name:	EPSTEIN, JEFFREY EDWARD
Date of Birth:	01/20/1953
Encounter Date:	07/06/2019 21:38

Sex: Provider:

Reg #:	76318-054
Race:	WHITE
Facility:	NYM

Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by . Cosign documentation will be displayed on the following page. Page 048 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) freedom of Information and Privacy Act Generated 07/06/2019 21:56 bj PA-C Bureau of Prisons - NYM Page 6 of 6 EFTA00073879 # Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: Provider: Encounter Date: 07/06/2019 21:38 Cosigned with New Encounter Note by on 07/07/2019 00:17. Page 049 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) freedom of Information and Privacy Act of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073880 # Bureau of Prisons Health Services History & Physical | Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | :--- | | Date of Birth: 01/20/1953 | Provider: | Facility: NYM | Unit: H01 | | 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 Page 050 of 148 - **Weight Loss:** No Withheld pursuant to exemption - **Fever:** No (b)(6); (b)(7)(A); (b)(7)(C) - **Cough:** No of the Freedom of Information and Privacy Act - **Comments:** of the Freedom of Information and Privacy Act **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 Paris x 3 weeks up until arrest No tattoos Generated 07/09/2019 13:03 by Page 1 of 13 Bureau of Prisons - NYM EFTA00073881

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

Reg #:	76318-054
Facility:	NYM
Unit:	H01

Comments:

Chlamydia in 2015, treated Chicken pox in childhood

Withheld pursuant to exemption

Abuse History: Denied Physical: No Emotional: No Sexual: No of the Freedom of Information and Privacy Act Comments: Denies Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 2 of 13 EFTA00073882

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

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
Unit:	H01

## Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal Behavior: Cooperative General Appearance: Normal 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: Page 052 of 148 Withheld pursuant to exemption Substance Use History: Denied (b) (6) ; (b)(7)(A) ; (b)(7)(C) Current Painful Condition: Depied of the Freedom of Information and Privacy Act 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 EFTA00073883

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

Sex: Provider: M Race: WHITE

Reg #:	76318-054
Facility:	NYM
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: ## Page 053 of 148 Withheld pursuant to exemption (b) (6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 4 of 13 EFTA00073884

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

Reg #:	76318-054
Facility:	NYM
Unit:	H01

## immunizations: **Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered** - Documented Date: 07/09/2019 12:51 EST - Immunization Date: - Provider: [black text] - 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: [black text] Page 054 of 148 - Location: Withheld pursuant to exemption - Drug Mfg: $(b)(6);(b)(7)(A);(b)(7)(C)$ - Lot Number: of the Freedom of Information and Privacy Act - Dosage: - Route: - Exp Dt: - Comments: **Smallpox Series Administration: History Unknown, Not Administered** - Documented Date: 07/09/2019 12:51 EST - Immunization Date: - Provider: [black text] - 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 07/09/2019 13:03 by Bureau of Prisons - NYM Page 5 of 13 EFTA00073885

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

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
Unit:	H01

Page 6 of 13 EFTA00073886

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

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
Unit:	H01

Date	Time	Inches	Cm	Provider
Weight:
Date	Time	Lbs	Kg	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: Yes Country of Birth: USA

Patient Education Assessments:
Date	Ed Yrs	Occupation	Learns Best By	Primary Language	Barriers to Education
07/09/2019	12	Banker	Speaking/Listening	English	None

Age at Death:	74
Cause of Death:	Diabetes complications
Significant Illnesses:
	Diabetes
	Heart Disease

Age at Death:	81
Cause of Death:	Kidney Failure
Significant Illnesses:	Heart Disease
Comments:
Family History - Sibling:
Number of Siblings:	1
Significant Illnesses:

Comments: Past Hospitalization: # Reason Acute Appendicitis **Complications:** None **Comments:** # Head: Normal: Yes Comments: Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 7 of 13 EFTA00073887

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

Sex: Provider: M Race: WHITE

Reg #:	76318-054
Facility:	NYM
Unit:	H01

## Eyes:

EOMI: Yes

Icterus: No

Conjunctival Inflammation: No

Pupils : Yes

Pupil Size Rt:

Pupil Size Lt:

Pupils Comments:

Fundi Vessels Nicking: No

Fundi Vessels Discs Flat:Yes

Fundi Vessels Discs Sharp Margins: Yes

Fundi Vessels Grounds Abnormal: No

Eyes Comments:

Vision Screen 07/09/2019 12:52 Blindness:
Distance Vision:	OD: 100	OS: 70	OU:	OD:	OS	OU:
Near Vision:	OD:	OS:	OU:	OD:	OS:	OU:

Ishihara Color Test: Withheld pursuant to exemption

Comments:	Needs evaluation with optometrist.
Ears:	of the Freedom of Information and Privacy Act

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 Page 8 of 13 Bureau of Prisons - NYM