Epstein Secrets

1 Exam: General Affect Waist Circum Provider MD Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears Ott Pulmonary Ausculta

Referred to Sick Call: Radiographs authorized: PAs• . Prophylaxis auUtortzect Yes I No (Approval var 18 months from examination date) EPNs: Panorox iPc t Nan= i 9 4t, n -376 1-rite_ E. Dentist Si nature: 1,3" it 7‘ lisznben 3 IS= OS-1/4\ Institution: MCC NEW YORK Date: 7- 06 -1 9. Si

.K.9 Waist Circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears Ott Pulmonary Ausculta

nt Retuned to Sick Call: Radiographs authorized: FAa- . Prophylaxis augtortzect Yes I No (Approval var 18 months from examination date) EPNs: Panorox iPc t Nemec i 9 Skin teS ti E Den' ! Nu isitsr _7‘ tsts.mben 3 I Sr- OSN Institution:/ / MCC NEW YORK Date: 7- 26 -1 9. Signature Block/St

.K.9 Waist Circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears O Pulmonary Auscultati

nt Referred to Sick Colt Radiographs authorized: PM. . Prophylaxis authorizect Yes I No (Approval var 18 months from examination date) BW5: Panorox :ga t Narrar. , 9 SA.C.4 O -5;SV7 -42_ti 2- D ' I alur : 1)17-5 istur Number: i I \ Institution: / MCC NEW YORK Date: 7 .- 74 -19. /Stamp