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Jail record · July 9, 2019

Bureau of Prisons intake health exam for Jeffrey Epstein, July 9, 2019

Intake medical history and physical for Jeffrey Epstein at MCC New York, covering health, HIV testing, mental health, vitals, and medications.Machine-written summary

EFTA00121336

Bureau of Prisons Health Services History & Physical

Inmate Name:EPSTEIN, JEFFREY EDWARDSex:M Race:WHITE MLPReg #:76318-054
Date of Birth:01/20/1953Provider:Facility:NYM
Encounter Date:07/09/2019 12:35Unit:H01
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 Paris x 3 weeks up until arrest
  No tattoos

Generated 07/09/2019 13:03 by

Page 1 of 13

MLP

Bureau of Prisons - NYM

EFTA00121337

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

Comments: Denies

Generated 07/09/2019 13:03 by

Page 2 of 13

MLP

Bureau of Prisons - NYM

EFTA00121338

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

MLP

Page 3 of 13

Bureau of Prisons - NYM

EFTA00121339

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/09/2019 12:35
Sex:MRace: WHITE
Provider:■MLP
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:

Generated 07/09/2019 13:03 by

Page 4 of 13

MLP

Bureau of Prisons - NYM

EFTA00121340

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/09/2019 12:35
Sex:MRace: WHITE
Provider:■MLP
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: [ ] .MLP

  • 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: [ ] .MLP

  • 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: [ ] .MLP

  • 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

MLP

Bureau of Prisons - NYM

Page 5 of 13

EFTA00121341

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

Temperature:

DateTimeFahrenheitCelsiusLocationProvider
07/09/201912:49 NYM97.336.3Oral.MLP

Pulse:

DateTimeRate Per MinuteLocationRhythmProvider
07/09/201912:4982Via MachineRegular. MLP

Respirations:

DateTimeRate Per MinuteProvider
07/09/201912:49 NYM16.MLP

Blood Pressure:

DateTimeValueLocationPositionCuff SizeProvider
07/09/201912:49 NYM117/66Right ArmSittingAdult-regular. MLP

SaO2:

DateTimeValue(%)AirProvider
07/09/201912:49 NYM97Room Air. MLP

Height:

DateTimeInchesCmProvider
07/09/201912:49 NYM70.0177.8. MLP

Generated 07/09/2019 13:03 by .MLP Bureau of Prisons - NYM

Page 6 of 13

EFTA00121342

DateTimeInchesCmProvider
Weight:
DateTimeLbsKgWaist Circum.Provider
07/09/201912:49 NYM194.488.2.MLP
Prosthetic Devices/Equipment: Denied
Tobacco Usage: Denied
General Social History:
Foreign Travel:
Born in USA: Yes
Country of Birth: USA
Patient Education Assessments:
DateEd YrsOccupationLearns Best ByPrimary LanguageBarriers to Education
07/09/201912 BankerSpeaking/ListeningEnglishNone
Family History - Father:
Age at Death: 74
Cause of Death: Diabetes complications
Significant Illnesses:
Diabetes
Heart Disease
Comments:
Family History - Mother:
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:
ReasonLocationWhen
Acute AppendicitisMount Sinai Hospital1990
Complications: None
Comments:
Head:
Normal: Yes
Comments:

Generated 07/09/2019 13:03 by

Bureau of Prisons - NYM

MLP

Page 7 of 13

EFTA00121343

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/09/2019 12:35
Sex:MRace: WHITE
Provider:■.MLP
Reg #:76318-054
Facility:NYM
Unit:H01
EOMI: Yes
Icterus: No
Conjunctival Inflammation: No
Pupils PERRLA: 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:

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

MLP

Page 8 of 13

Bureau of Prisons - NYM

EFTA00121344

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/09/2019 12:35
Sex:MRace: WHITE
Provider:MLP
Reg #:76318-054
Facility:NYM
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 II-XII: 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 07/09/2019 13:03 by

MLP

Page 9 of 13

Bureau of Prisons - NYM

EFTA00121345

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

Thorax:

Contour Normal: Yes
Increased AP Diameter: No
Asymmetrical Expansion: No
Lungs Clear: Yes
Wheezes: No
Crackles: No
Rhonchi: No
Rales: No
Accessory Muscle Use: No
Comments:

Spine:

Deformity: No
Full ROM: Yes
Tenderness: No
Comments:

Cardiovascular:

RRR: Yes
Normal S1/S2: Yes
Murmurs: No
Carotid Bruits: No
JVD: No
Arteries:RightLeft
Radial:
Femoral:
Dorsalis Pedis:
Post. Tibialis:

Comments:

Generated 07/09/2019 13:03 by

MLP

Page 10 of 13

Bureau of Prisons - NYM

EFTA00121346

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

Abdomen:

Normal Contour:Yes
Scaphoid:No
Obese:No
Gravid:No
Hernias:No
Bruits:No
Masses:No
Scars:No
Tenderness:No
Organomegaly:No
Active Bowel Sounds:Yes
Comments:

Extremities:

Nails Clubbing: No
Nails Cyanosis: No
Lower Extremity Edema - Right: None
Lower Extremity Edema - Left: None
Atrophy: No
Amputations: No
Other Deformities: No
Varicosities: No
Calf Tenderness: No
Pulse Deficit: No
Strength:RightLeft
Arm:
Leg:
Full ROM:RightLeft
Arm:YesYes
Leg:YesYes
Comments:

Comments:

Generated 07/09/2019 13:03 by

Page 11 of 13

MLP

Bureau of Prisons - NYM

EFTA00121347

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/09/2019 12:35
Sex:MRace: WHITE
Provider:MLP
Reg #:76318-054
Facility:NYM
Unit:H01
RightLeft
Biceps:
Patellar:
Brachioradialis:
Achilles:
Sensation:
    Vibratory: Yes
    Light Touch: Yes
    Pin Prick: Yes
Comments:
GU:
Chaperoned By:
Rectum: Not Done
Comments: Refused.
Male Genitalia: Not Done
Comments: Refused.
Skin:
Normal: Yes
Rash: No
Redness: No
Abnormal Pigmentation: No
Abnormal Lesions/Growths: No
Comments:
Lymphatics:
Adenopathy: No
Comments:
Potential Items For Follow-up:
Item
Travel Outside US
Other Infectious Disease History
Rectum Not Done
Male Genitalia Not Done
PPD Administration Not Performed
Comments:
Patient has a history of constipation

Generated 07/09/2019 13:03 by

Page 12 of 13

MLP

Bureau of Prisons - NYM

EFTA00121348

Inmate Name:EPSTEIN, JEFFREY EDWARDReg #:76318-054
Date of Birth:01/20/1953Sex:MRace: WHITEFacility:NYM
Encounter Date:07/09/2019 12:35Provider:MLPUnit:H01
Cleared For Food Services: Yes
Health Problems Newly Identified During This Encounter:
Health Problem
Constipation, unspecified - Current -
New Medication Orders:
Rx#MedicationOrder DatePrescriber Order
Bisacodyl E.C. Tablet07/09/2019 12:355 mg Orally at bedtime PRN x 10 day(s)

Indication: Constipation, unspecified

Disposition:

Follow-up at Sick Call as Needed

Instructed inmate how to obtain medical, dental, and mental health care.

Copay Required: NoCosign Required: Yes

Telephone/Verbal Order: No

Completed by . MLP on 07/09/2019 13:03

Requested to be cosigned by MD.

Cosign documentation will be displayed on the following page.

Generated 07/09/2019 13:03 by

MLP

Page 13 of 13

Bureau of Prisons - NYM

EFTA00121349

Bureau of Prisons Health Services Cosign/Review

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

Cosigned by MD on 07/11/2019 22:41.

Bureau of Prisons - NYM

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Retrieved from https://epstein-index.org/documents/ds9-efta00121336/.