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Jail record · July 9, 2019

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

Bureau of Prisons health services history and physical for Epstein at MCC New York on his first day in custody, covering medical, mental health, and screening findingsMachine-written summary

EFTA00139039

Bureau of Prisons Health Services History & Physical

Inmate Name: EPSTEIN, JEFFREY EDWARDSex: MRace: WHITEReg #: 76318-054
Date of Birth: 01/20/1953Provider:MLPFacility: 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

SDNY_00017403 Page 1 of 13

MLP

Bureau of Prisons - NYM

EFTA00139040

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

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

MLP

Bureau of Prisons - NYM

SDNY_00017404 Page 2 of 13

EFTA00139041

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

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

Bureau of Prisons - NYM

SDNY_00017405 Page 3 of 13

EFTA00139042

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

MLP

Bureau of Prisons - NYM

SDNY_00017406 Page 4 of 13

EFTA00139043

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

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

SDNY_00017407

Page 5 of 13

EFTA00139044

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

Immunization Date:

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

SDNY_00017408

Page 6 of 13

EFTA00139045

DateTimeInchesCmProvider
Weight:
DateTimeLbsKgWaist Circum.Provider
07/09/201912:49 NYM194.488.2MLP
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
07/09/201912BankerSpeaking/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

SDNY_00017409

Page 7 of 13

EFTA00139046

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

| Description | Information |

| :--- | :--- |

| 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: | |

Vision Screen 07/09/2019 12:52

Blindness:

Distance Vision: OD: 100 OS: 70

Near Vision: OD: OS:

Ishihara Color Test:

Tonometry: L: R:

Comments: Needs evaluation with optometri

Ears:

Right Ear: Canal patent

Left Ear: Canal na’

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

Bureau of Prisons - NYM

SDNY_00017410 Page 8 of 13

EFTA00139047

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

Sex:

Provider:

M Race: WHITE

Y. 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

Bureau of Prisons - NYM

SDNY_00017411 Page 9 of 13

EFTA00139048

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

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
Radial:
Femoral:
Dorsalis Pedis:
Post. Tibialis:

Comments:

Generated 07/09/2019 13:03 by

MLP

Bureau of Prisons - NYM

SDNY_00017412 Page 10 of 13

EFTA00139049

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

M Race: WHITE

Y. 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

Right

Left

Right

Arm:

Yes

Left

Leg:

Yes

Yes

Comments:

Yes

Generated 07/09/2019 13:03 by

MLP

Bureau of Prisons - NYM

SDNY 00017413 Page 11 of 13

EFTA00139050

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

Sex:

Provider:

M Race: WHITE

  1. MLP
Reg #:76318-054
Facility:NYM
Unit:H01

Reflexes:

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

MLP

SDNY_00017414 Page 12 of 13

Bureau of Prisons - NYM

EFTA00139051

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

Cleared For Food Services: Yes

Health Problems Newly Identified During This Encounter:

Health Problem

Constipation, unspecified - Current -

Rx#Medication
Bisacodyl E.C. Tablet
Order Date
07/09/2019 12:35

Prescriber Order

Indication: Constipation, unspecified

5 mg Orally at bedtime PRN x 10 day(s)

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

Bureau of Prisons - NYM

SDNY_00017415 Page 13 of 13

EFTA00139052

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

SDNY_00017416

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