</p>
<table>
<tr>
<td valign="top">HTML:</td>
<td>
<h3>Patient Information</h3>
</td>
</tr>
<tr>
<td valign="top">First and Last Name:</td>
<td>test patient test last name</td>
</tr>
<tr>
<td valign="top">Date of Birth:</td>
<td>
<h4>Date of Birth</h4>
</td>
</tr>
<tr>
<td valign="top">DOB - Month:</td>
<td>February</td>
</tr>
<tr>
<td valign="top">DOB - Day:</td>
<td>1</td>
</tr>
<tr>
<td valign="top">DOB - Year:</td>
<td></td>
</tr>
<tr>
<td valign="top">Social Security #:</td>
<td>3434234rwer</td>
</tr>
<tr>
<td valign="top">Preferred Language:</td>
<td>English</td>
</tr>
<tr>
<td valign="top">SEX:</td>
<td>
<h3>Sex</h3>
</td>
</tr>
<tr>
<td valign="top">MARITAL STATUS:</td>
<td>
<h3>Marital Status</h3>
</td>
</tr>
<tr>
<td valign="top">Sex:</td>
<td>Male</td>
</tr>
<tr>
<td valign="top">Marital Status:</td>
<td>Single</td>
</tr>
<tr>
<td valign="top">Race:</td>
<td>sdasd</td>
</tr>
<tr>
<td valign="top">Ethnicity:</td>
<td>dasd</td>
</tr>
<tr>
<td valign="top">Preferred Pharmacy:</td>
<td>dsad</td>
</tr>
<tr>
<td valign="top">Location:</td>
<td>dasda</td>
</tr>
<tr>
<td valign="top">Primary Care Doctor:</td>
<td>dasda</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>8128884151</td>
</tr>
<tr>
<td valign="top">Weight:</td>
<td>123</td>
</tr>
<tr>
<td valign="top">Height:</td>
<td>343</td>
</tr>
<tr>
<td valign="top">Address:</td>
<td>
<h3>Address</h3>
</td>
</tr>
<tr>
<td valign="top">Street:</td>
<td>asdasdas</td>
</tr>
<tr>
<td valign="top">City:</td>
<td>dfsdfds</td>
</tr>
<tr>
<td valign="top">State:</td>
<td>fsdfsd</td>
</tr>
<tr>
<td valign="top">Zip:</td>
<td>74136</td>
</tr>
<tr>
<td valign="top">Country:</td>
<td>US</td>
</tr>
<tr>
<td valign="top">Primary Phone:</td>
<td>8128884151</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>harsh@bugendaitech.com</td>
</tr>
<tr>
<td valign="top">Alternate Phone:</td>
<td>543534534</td>
</tr>
<tr>
<td valign="top">Occupation:</td>
<td>IT</td>
</tr>
<tr>
<td valign="top">Emergency Contact:</td>
<td>
<h3>Emergency Contact</h3>
<p></p>
<p>- Please list the person who will be accompanying you during treatment</p>
</td>
</tr>
<tr>
<td valign="top">First and Last Name - Emergency:</td>
<td>fdsfdsf</td>
</tr>
<tr>
<td valign="top">Relationship to Patient:</td>
<td>fsdfsdf</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>harsh@bugendaitech.com</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>8128884151</td>
</tr>
<tr>
<td valign="top">Other Relevant Personal Remarks::</td>
<td>fsdfdsfds</td>
</tr>
<tr>
<td valign="top">DRUGS CURRENTLY BEING USED:</td>
<td>
<h3>Drugs Currently Being Used</h3>
</td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td>fsdfsdf</td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>10</td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Direct</td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td></td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td></td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td></td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td></td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td></td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td></td>
</tr>
<tr>
<td valign="top">Most Recent Attempt to Withdraw:</td>
<td>
<h3>Most Recent Attempt to Withdraw</h3>
</td>
</tr>
<tr>
<td valign="top">Institution or Clinic:</td>
<td>asdasdas</td>
</tr>
<tr>
<td valign="top">Date:</td>
<td>12/17/2020</td>
</tr>
<tr>
<td valign="top">General remarks about your withdrawal attempts:</td>
<td>dsadasd</td>
</tr>
<tr>
<td valign="top">Craving scale while “clean"::</td>
<td>
<h3>Craving scale while “clean":</h3>
</td>
</tr>
<tr>
<td valign="top">Craving scale while “clean"::</td>
<td>Mild</td>
</tr>
<tr>
<td valign="top">Please Specify:</td>
<td>dasdad</td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>
<h3>Methadone or Suboxone Maintenance?</h3>
</td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">For How Long?:</td>
<td>dasdad</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>
<h3>Have you ever received psychiatric treatment?</h3>
</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>dasdad</td>
</tr>
<tr>
<td valign="top">Prior suicide attempts?:</td>
<td>
<h3>Prior suicide attempts?</h3>
</td>
</tr>
<tr>
<td valign="top">Prior suicide attempts?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">If so, when?:</td>
<td></td>
</tr>
<tr>
<td valign="top">Past Medical History:</td>
<td>
<h3>Past Medical History</h3>
<p><i>Medication currently being used (other than drugs mentioned above)</i></p>
</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td>dasd</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>das</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>dsa</td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>das</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td></td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td></td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td></td>
</tr>
<tr>
<td valign="top">Route:</td>
<td></td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td></td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td></td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td></td>
</tr>
<tr>
<td valign="top">Route:</td>
<td></td>
</tr>
<tr>
<td valign="top">Allergies (Medications, Food, etc.)?:</td>
<td>
<h3>Allergies (Medications, Food, etc.)?</h3>
</td>
</tr>
<tr>
<td valign="top">Allergies (Medications, Food, etc.)?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify and describe reactions::</td>
<td></td>
</tr>
<tr>
<td valign="top">Past Surgeries?:</td>
<td>
<h3>Past Surgeries?</h3>
</td>
</tr>
<tr>
<td valign="top">Past Surgeries?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Hospitalization in the last two years?:</td>
<td>
<h3>Hospitalization in the last two years?</h3>
</td>
</tr>
<tr>
<td valign="top">Hospitalization in the last two years?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Adverse reactions to anesthesia in the past?:</td>
<td>
<h3>Adverse reactions to anesthesia in the past?</h3>
</td>
</tr>
<tr>
<td valign="top">Adverse reactions to anesthesia in the past?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Emergency room visits in the last year?:</td>
<td>
<h3>Emergency room visits in the last year?</h3>
</td>
</tr>
<tr>
<td valign="top">Emergency room visits in the last year?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Accidents? (work, car etc):</td>
<td>
<h3>Accidents? (work, car etc)</h3>
</td>
</tr>
<tr>
<td valign="top">Accidents? (work, car etc):</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Head Injuries?:</td>
<td>
<h3>Head Injuries?</h3>
</td>
</tr>
<tr>
<td valign="top">Head Injuries?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Loss of consciousness?:</td>
<td>
<h3>Loss of consciousness?</h3>
</td>
</tr>
<tr>
<td valign="top">Loss of consciousness?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Loss of consciousness? Seizures?:</td>
<td>
<h3>Seizures?</h3>
</td>
</tr>
<tr>
<td valign="top">Loss of consciousness? Seizures?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Heart disease?:</td>
<td>
<h3>Heart disease?</h3>
</td>
</tr>
<tr>
<td valign="top">Heart disease?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Lung disease?:</td>
<td>
<h3>Lung disease?</h3>
</td>
</tr>
<tr>
<td valign="top">Lung disease?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Liver disease / infections?:</td>
<td>
<h3>Liver disease / infections?</h3>
</td>
</tr>
<tr>
<td valign="top">Liver disease / infections?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Kidney disease / problem?:</td>
<td>
<h3>Kidney disease / problem?</h3>
</td>
</tr>
<tr>
<td valign="top">Kidney disease / problem?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>
<h3>Diabetes?</h3>
</td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>
<h3>Ulcers?</h3>
</td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">High Blood Pressure?:</td>
<td>
<h3>High Blood Pressure?</h3>
</td>
</tr>
<tr>
<td valign="top">High Blood Pressure?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Asthma or shortness of breath?:</td>
<td>
<h3>Asthma or shortness of breath?</h3>
</td>
</tr>
<tr>
<td valign="top">Asthma or shortness of breath?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>
<h3>Obstructive sleep apnea?</h3>
</td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>
<h3>Pregnancy?</h3>
</td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
</table>
<p></p>
