EFTA00134711 Bureau of Prisons Health Services History & Physical # Health Services History & Physical **Institute Name:** EPSTEIN, JEFFREY EDWARD **Date of Birth:** 01/20/1953 **Encounter Date:** 07/09/2019 12:35 **Sex:** M **Race:** WHITE **Facility:** NYM **Unit:** 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 SDN1_00000968 Bureau of Prisons - NYM | EFTA_00000177 | | :--- | :--- | This is a simple text representation of a table with two columns. The first column contains the label "EFTA_00000177", and the second column contains the corresponding data. No formatting or special characters are present. EFTA00134712 # Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE Provider: ## 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 Generated 07/09/2019 13:03 by Page 2 of 13 SDNY_00000969 Bureau of Prisons - NYM | EFTA_00000178 | | :--- | :--- | This is a simple Markdown document with no headings, paragraphs, or tables. It contains just one line of text: "EFTA_00000178". EFTA00134713 Immate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE Provider: 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 | EFTA_00000179 | | :--- | :--- | This is a simple Markdown document with no headings, paragraphs, or tables. It contains just one line of text. EFTA00134714
Inmate Name:EPSTEIN, JEFFREY EDWARDReg #:76318-054
Date of Birth:01/20/1953Sex:MRace: WHITEFacility: NYM
Encounter Date:07/09/2019 12:35Provider: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 SDNY_00000971 Bureau of Prisons - NYM EFTA_00000180 EFTA00134715 ## Immunizations: ### Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered - Documented Date: 07/09/2019 12:51 EST - Immunization Date: - Provider: [Provide provider name] - 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: [Provide provider name] - 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: [Provide provider name] - 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 on 07/09/2019 13:03 by Bureau of Prisons - NYM EFTA_00000181 EFTA00134716 ### Immunization Date: Provider: [blank] ### 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: [blank] ### Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: ### Comments: Temperature: | Date | Time | Fahrenheit | Celsius | Location | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 97.3 | 36.3 | Oral | [blank] | ### Pulse: | Date | Time | Rate Per Minute | Location | Rhythm | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 | 82 | Via Machine | Regular | [blank] | ### Respirations: | Date | Time | Rate Per Minute | Provider | | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 16 | [blank] | ### Blood Pressure: | Date | Time | Value | Location | Position | Cuff Size | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 117/66 | Right Arm | Sitting | Adult-regular | [blank] | ### SaO2: | Date | Time | Value(%) | Air | Provider | | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 97 | Room Air | [blank] | ### Height: | Date | Time | Inches | Cm | Provider | | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 70.0 | 177.8 | [blank] | Generated on 07/09/2019 13:03 by [Bureau of Prisons - NYM] EFTA_00000182 EFTA00134717 ## 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 | Date | Time | Inches | Cm | Provider | | :--- | :--- | :--- | :--- | :--- | | Date | Time | Lbs | Kg | Waist Circum. | | 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 | ## 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: | Reason | Location | When | | :--- | :--- | :--- | | Acute Appendicitis | Mount Sinai Hospital | 1990 | | Complications: None | | | | Comments: | | | Head: - Normal: Yes - Comments: | # Page 7 of 13 SDNY_00000974 | EFTA_00000183 | | :--- | :--- | This is a simple Markdown representation of the text from the image. The text is split into two lines, with "EFTA_00000183" on one line and the rest on another. There are no headings or paragraphs present in the image. EFTA00134718 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Date of Birth: 01/20/1953 | Sex: M | Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | :--- | :--- | | Encounter Date: 07/09/2019 12:35 | Provider: | | 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:** With Corrective **Distance Vision:** OD: 100 OS: 70 OU: OD: OS OU: **Near Vision:** OD: OS: OU: OD: OS: OU: **Ishihara 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 # Page 8 of 13 SDNY_00000975 Bureau of Prisons - NYM EFTA_00000184 EFTA00134719 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | | P | | 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 # Page 9 of 13 SDNY_00000976 Bureau of Prisons - NYM | EFTA_00000185 | | :--- | :--- | This is a simple Markdown representation of the text from the image. The text is split into two lines, with "EFTA_00000185" on one line and the rest on another. There are no headings or paragraphs present in the image.