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

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 EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	M	Race: WHITE	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¶

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.¶