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INSERT INTO `wp_wpml_mails` VALUES (1,'2020-12-20 15:26:16','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>ben</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>waismannben@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>test</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: waismannben@gmail.com <waismannben@gmail.com>','',NULL,'1.9.7'),(2,'2020-12-20 15:26:16','45.79.210.65','waismannben@gmail.com','Submission Confirmation ','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>ben</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>waismannben@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>test</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(3,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>45.237.111.29</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(4,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>45.237.111.29</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(5,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>159.146.10.171</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(6,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>159.146.10.171</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(7,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>3 failed login attempts (0 lockout(s)) from IP <b>62.210.177.162</b> and it was blocked for 20 minutes<br>Last user attempted: <b>waismannben</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(8,'2020-12-20 18:56:12','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Christopher Hartsell</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>ryanhartsell19@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7047960579</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Opiate detox</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: ryanhartsell19@gmail.com <ryanhartsell19@gmail.com>','',NULL,'1.9.7'),(9,'2020-12-20 18:56:12','45.79.210.65','ryanhartsell19@gmail.com','Submission Confirmation ','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Christopher Hartsell</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>ryanhartsell19@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7047960579</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Opiate detox</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(10,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2a02:ab88:101:b800:5419:e1be:88ec:a69a</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(11,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2800:810:47f:3a41:1858:b6d6:7623:3453</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(12,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2a02:ab88:101:b800:5419:e1be:88ec:a69a</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(13,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2800:810:47f:3a41:1858:b6d6:7623:3453</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(14,'2020-12-20 19:57:17','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Heather Blair','<p><table></table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(15,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>115.230.127.176</b> and it was blocked for 20 minutes<br>Last user attempted: <b>pages</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(16,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>115.230.127.176</b> and it was blocked for 24 hours<br>Last user attempted: <b>pages</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(17,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>5.188.62.140</b> and it was blocked for 20 minutes<br>Last user attempted: <b>ps-apai</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(18,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>5.188.62.140</b> and it was blocked for 24 hours<br>Last user attempted: <b>gal-holesinthenet</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(19,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>62.210.177.162</b> and it was blocked for 20 minutes<br>Last user attempted: <b>ps-apai</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(20,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>188.165.210.14</b> and it was blocked for 20 minutes<br>Last user attempted: <b>waismannben</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(21,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>62.210.177.162</b> and it was blocked for 24 hours<br>Last user attempted: <b>ps-apai</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(22,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>77.203.231.195</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(23,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>77.203.231.195</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(24,'2020-12-21 11:33:55','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Gabriel Jose Rodriguez','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Gabriel Jose Rodriguez</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>February</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>6</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1991</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>598306327</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>english</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>hispanic</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Orlando</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>walgreens</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>4077301237</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>4074318918</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>210</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5\'11</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>3229 Landtree Pl</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Orlando</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>FL</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>32812</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>14077301237</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rodwelds@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>welder</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>ana rivera</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>mother</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rodwelds@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9043770462</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>heroin</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>half gram</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>nasal</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>river oaks treatment center</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>01/01/2021</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>i went to the treatment center for about 30 days at the time i was withdrawing of methadone and heroin i was able to break the methadone but once i got out of treatment i was only clean for about a week and started with heroin again because of cravings.</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Severe</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>when i was in treatment they started me on a suboxone taper after 7 days which helped with cravings but once i left treatment i didnt have a suboxone prescription which made it difficult for me to stay clean and i still was feeling mild withdraws at the time as well. </td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>methadone for about a year before i went into treatment and suboxone for 2 to 3 weeks while in treatment at Riveroaks my last day taking methadone was on december 31 and i havent had any dose of suboxone since leaving treatment.</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>counseling at river oaks</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>shoulder pain from a accident at work</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>got hit with a blind flange on my shoulder while trying to install it at work </td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>i was told at the treatment center i might have sleep apnea do to my snoring i wasnt told anything else about it.</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(25,'2020-12-21 11:38:17','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Lakisha V Washington</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>lakisha.washington@my.tccd.edu</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>6822034847</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I was wondering what is the cost of your treatment program? Does a person have to keep coming into clinic everyday? Is this medication like methadone or Suboxygen ?<br />\nWhat health insurance do you take? Is there any grant funding for people who can’t afford it or will it be based on in one.. like a pay scale </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: lakisha.washington@my.tccd.edu <lakisha.washington@my.tccd.edu>','',NULL,'1.9.7'),(26,'2020-12-21 11:38:17','45.79.210.65','lakisha.washington@my.tccd.edu','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Lakisha V Washington</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>lakisha.washington@my.tccd.edu</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>6822034847</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I was wondering what is the cost of your treatment program? Does a person have to keep coming into clinic everyday? Is this medication like methadone or Suboxygen ?<br />\nWhat health insurance do you take? Is there any grant funding for people who can’t afford it or will it be based on in one.. like a pay scale </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(27,'2020-12-21 13:03:41','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Amram malka','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Amram malka</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>June</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>29</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1981</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>768929287</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English </td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>White</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Jewish </td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Cvs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>2701 Stirling rd Fort Lauderdale </td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>160</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>6.2</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>5700 Park Rd</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Dania Beach</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Florida</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>33312</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9548029564</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>amimalka@yahoo.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9543832876</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Efi Nimzer </td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Friend</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>hagiga8@hotmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9543832876</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Oxycodone </td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>Two pills a day</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Pills</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Xanax </td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>One evry two days</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Pills</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Home</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/19/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Knees surgery </td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Colonoscopy </td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Burns </td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(28,'2020-12-21 13:32:25','45.79.210.65','donp0702@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Donald Freeman</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>donp0702@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2197437830</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Hi, I would like to get off opiates. How much does this program cost?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(29,'2020-12-21 13:32:25','45.79.210.65','waismannben@gmail.com','New message from Donald Freeman','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Donald Freeman</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>donp0702@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2197437830</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Hi, I would like to get off opiates. How much does this program cost?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: donp0702@gmail.com <donp0702@gmail.com>','',NULL,'1.9.7'),(30,'2020-12-21 17:13:13','45.79.210.65','test@tes.co','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>tett</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>test@tes.co</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>0526493804</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>gffhgfh</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Referral</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(31,'2020-12-21 17:13:13','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from tett - Contact Page','</p>\n<p>tett</p>\n<p>test@tes.co</p>\n<p>0526493804</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: test@tes.co <test@tes.co>','',NULL,'1.9.7'),(32,'2020-12-21 17:26:17','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Melanie Bell','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Melanie Bell</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>melaniebell155@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>716-777-6033</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>I have an addiction to hydrocodone and alcohol I just can not kick and I need some advice on how to kick this I have daughters and I don\'t know how much longer I can do this</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(33,'2020-12-21 19:53:35','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Alisha Carr </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>lishcarr@icloud.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>1-760-396-7034 </td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Interested in ANR- have issues with overheating-aka Hyperthermia . Have PPO insurance through employer or cash. Have a few questions, looking forward to speaking with you. Thank you so much for your help and your time</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: lishcarr@icloud.com <lishcarr@icloud.com>','',NULL,'1.9.7'),(34,'2020-12-21 19:53:36','45.79.210.65','lishcarr@icloud.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Alisha Carr </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>lishcarr@icloud.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>1-760-396-7034 </td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Interested in ANR- have issues with overheating-aka Hyperthermia . Have PPO insurance through employer or cash. Have a few questions, looking forward to speaking with you. Thank you so much for your help and your time</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(35,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>192.95.30.65</b> and it was blocked for 20 minutes<br>Last user attempted: <b>waismannben</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(36,'2020-12-21 20:30:22','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Michael','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Michael</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>bromonty95@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7245909391</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>I wish anyone can help... I want my life back my family... Worried if I\'ll ever have that bacl</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(37,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>14.139.87.194</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(38,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>108.162.28.6</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(39,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>81.145.194.114</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(40,'2020-12-22 06:10:21','45.79.210.65','thickdupcaddy33@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Emily Buchanan</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>thickdupcaddy33@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9048943286</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>I have been on opiates since i was 20yrs old. Im 34 now and i was diagnosed with 3 herniated discs in my back. PTSD. Panic Disorder. Depression. I want to know what life is without dependency. To actually live for once instead of chase. I want this more than anything. Im a single mother of 3 boys i know they see alot more then we think. There my best friends ive hid my addiction from them but i know when im disappointed someone at times. When i set my mind to something i wont stop until ive accomplished in its entirety. My boys deserve the best version of me correct? I need this more then anything. I hope you contact me. Look forward to speaking with you soon. Thank you.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(41,'2020-12-22 06:10:21','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Emily Buchanan - Contact Page','</p>\n<p>Emily Buchanan</p>\n<p>thickdupcaddy33@gmail.com</p>\n<p>9048943286</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: thickdupcaddy33@gmail.com <thickdupcaddy33@gmail.com>','',NULL,'1.9.7'),(42,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>14.139.87.194</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(43,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>80.71.13.138</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(44,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>115.4.56.5</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(45,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>110.93.222.250</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(46,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>110.93.222.250</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(47,'2020-12-22 08:53:35','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Colton Adams</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>coltonadams871@yahoo.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>+16067928443 </td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Detox</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: coltonadams871@yahoo.com <coltonadams871@yahoo.com>','',NULL,'1.9.7'),(48,'2020-12-22 08:53:36','45.79.210.65','coltonadams871@yahoo.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Colton Adams</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>coltonadams871@yahoo.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>+16067928443 </td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Detox</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(49,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>192.99.0.98</b> and it was blocked for 20 minutes<br>Last user attempted: <b>waismannben</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(50,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>177.198.103.112</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(51,'2020-12-22 12:23:05','45.79.210.65','lynns1927@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Lynn Lamb</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>lynns1927@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>804-716-2978</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Dear Dr. Kabemba, Christy, Paul, Robert and Everyone at ANR,</p>\n<p>I had to take a moment to let you know how you have changed my life. I am very aware of the opportunity you are giving me. There are no words to express my gratitude. I had nowhere to go and was completely lost when God steered me toward calling Christy. She gave me hope I had not had since I started this nightmare. When I spoke with Dr. Kabemba and he explained what ANR was going to do for me, the tears started flowing. I have not had this kind of hope since I started this nightmare. I promised God I would never give up, but I had no idea where to go. I prayed for years and one day He guided me to ANR. You are saving my life and giving me my life back,  I promise I will give back more than you give me. I want to give my testimony to the world. I also wanted to let you know I promise I will give back so much more than you are giving me. I . want to save others from going through what I have.  Let them know there is help out there and this does not have to be their life. </p>\n<p>ANR is the beginning of your new life. A life where you know how bad it can get and the gift of life you have been given.</p>\n<p>Please have a Merry Christmas and Happy New Year. You will all be in my prayers.</p>\n<p>Sincerely,</p>\n<p>Lynn </td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>How did you hear about us?</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(52,'2020-12-22 12:23:06','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Lynn Lamb - Contact Page','</p>\n<p>Lynn Lamb</p>\n<p>lynns1927@gmail.com</p>\n<p>804-716-2978</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: lynns1927@gmail.com <lynns1927@gmail.com>','',NULL,'1.9.7'),(53,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>177.198.103.112</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(54,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>5.39.64.46</b> and it was blocked for 20 minutes<br>Last user attempted: <b>waismannben</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(55,'2020-12-22 15:02:49','45.79.210.65','funk21@hotmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Lindsay Funk</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>funk21@hotmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>4138248919</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td> I’m addicted to heroin and fentanyl.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(56,'2020-12-22 15:02:49','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Lindsay Funk - Contact Page','</p>\n<p>Lindsay Funk</p>\n<p>funk21@hotmail.com</p>\n<p>4138248919</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: funk21@hotmail.com <funk21@hotmail.com>','',NULL,'1.9.7'),(57,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2a02:2149:885c:6d00:4c81:e527:b597:9cab</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(58,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2a02:2149:885c:6d00:4c81:e527:b597:9cab</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(59,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>185.157.14.51</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(60,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>185.157.14.51</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(61,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.231.56.80</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(62,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.231.56.90</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(63,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.231.56.80</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(64,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.231.56.90</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(65,'2020-12-22 18:53:31','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Rebecca S Cribb</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rebeccacribb1991@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8544446916</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I would like more information on ANR. </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: rebeccacribb1991@gmail.com <rebeccacribb1991@gmail.com>','',NULL,'1.9.7'),(66,'2020-12-22 18:53:31','45.79.210.65','rebeccacribb1991@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Rebecca S Cribb</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rebeccacribb1991@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8544446916</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I would like more information on ANR. </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(67,'2020-12-22 18:54:01','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Gabriel Martinez ','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Gabriel Martinez </td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>May</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>6</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1987</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>630565739</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>Englidsh</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>Mexican</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Hispanic</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Kroger </td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>8328059764</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>200</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>6</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>2111 seven maples dr </td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Kingwood</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Texas</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>77345</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8328059764</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>admartinez01@hotmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8328032026</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Eduardo Martinez</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Father</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>admartinez01@hotmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8328059764</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Opiatyes</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>Gram</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>IV</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Na</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/19/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Severe</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Not sure when</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Xanax</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>2mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>3 times a day</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Adderol</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>30mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>Twice a day</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Tramadol</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>50mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>2 three times a day</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Car accident dec 6</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>When not on opiates</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(68,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.231.56.93</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(69,'2020-12-22 19:09:42','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Audrey Storch','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Audrey Storch</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>March</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>28</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1959</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>ENGLISH</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>CAUCASIAN</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>JEWISH</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>TENS PHARMACY</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>ROSELAND, NJ 973-226-1200</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>DR. LISA RAACKE</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>551-996-8111</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>145</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5\'2\"</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>85 Four Seasons Drive</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>NORTH CALDWELL</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>NEW JERSEY</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>07006</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>973-650-5793</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>astorch@huggstogo.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>973-633-1242</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>Self Employed</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Michael Storch</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Spouse</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>mstorch@metrohydraulic.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>973-464-9555</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>I wish to safely and comfortably get off the opiods and Morphine I have been on for 20 years. I have significantly detoxed myself<br />\ndown in the last 18 months but due to DEA and doctors fears with the DEA I am having trouble continuing detoxing.</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Morphine 100mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>2</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Oxycodone 30mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>Every 6 hours </td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Xanax</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>1 as needed</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>N/A</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/22/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>I am being very successful for the past 18 months. I do not have mental addiction at all. Only physical.<br />\nChronic pain is making it harder but i wish to get totally off all to see my baseline. If the doctor would<br />\nallow me to continue my detox in a comfortable manner I would continue on my own but my previous pain<br />\nmanagement doctor of almost 20 years had to stop prescribing and the new one is incredibly difficult.</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>Doesn\'t apply. I don\'t crave it. Only when I am in pain do I need it.</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Long time ago. For anxiety and during Breast cancer in 1995</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Prevastatin</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>20mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>1 time </td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Levothyroxine</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>50 mcg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>1 time</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>Liothyronine</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>5 mcg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>1 time</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>ALL Anti inflammatories, Dairy anything liquid from a cow. Catapres</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Bilateral Knee Replacement 2017, March 1.<br />\nGallbladder removal 2 yrs ago?<br />\nOvaries removed same time as gallbladder<br />\nBreast cancer lumpectomy 1995<br />\nLymphnode Dissection 1995<br />\nNeck Fused 2007</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Fell on Thanksgiving small tears in right shoulder.</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Kidney stone in 1996</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>gestational in 1990. Injected 3x a day.<br />\nA1C is prediabetic last 10 years.</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>Bacterial long time ago</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>Rare but get reactive airway. Happened once this year<br />\nonce last year.</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(70,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.231.56.93</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(71,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2607:fea8:a460:5400:15:d569:965e:eb58</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(72,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2607:fea8:a460:5400:15:d569:965e:eb58</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(73,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>46.217.8.100</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(74,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>46.217.8.100</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(75,'2020-12-23 05:54:25','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Test Bugendaitech','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Test Bugendaitech</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>March</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>13</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>2000</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>156787</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>sfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsfe</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>sfdsfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>Pune</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>08874632864</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>34</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>56</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>Sector 76</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Noida</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Uttar Pradesh</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>201307</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>08874632864</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>Test@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>test</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>test</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>Test@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>08874632864</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>hfdgh</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>45</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>sdgfsg</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>gs</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/09/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(76,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>148.255.255.220</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(77,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>83.139.55.110</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(78,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>83.139.55.110</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(79,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>148.255.255.220</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(80,'2020-12-23 12:14:51','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Cassie Ann McCarty</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>cassiea.m.76@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>606210173</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I’m very interested in this procedure </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: cassiea.m.76@gmail.com <cassiea.m.76@gmail.com>','',NULL,'1.9.7'),(81,'2020-12-23 12:14:51','45.79.210.65','cassiea.m.76@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Cassie Ann McCarty</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>cassiea.m.76@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>606210173</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I’m very interested in this procedure </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(82,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2003:d0:9716:5633:dc74:a323:95e:ecb</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(83,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>176.118.111.133</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(84,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2003:d0:9716:5633:dc74:a323:95e:ecb</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(85,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>176.118.111.133</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(86,'2020-12-23 13:25:22','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Trisha pogue','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Trisha pogue</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>pogue.trishaen@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>3609369015</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>I need help to kick my haroin addiction. </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(87,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2a02:2149:885c:6d00:e5d5:1522:7fc5:21fe</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(88,'2020-12-23 15:26:28','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Denise Sigler</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>nise9541@sbcglobal.net</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2488903028</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I’m on Zubsolv after treatment for ac/chronic pain using Fentanyl patches for 10 years. What would I use for pain once I was treated at an ANR facility?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: nise9541@sbcglobal.net <nise9541@sbcglobal.net>','',NULL,'1.9.7'),(89,'2020-12-23 15:26:28','45.79.210.65','nise9541@sbcglobal.net','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Denise Sigler</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>nise9541@sbcglobal.net</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2488903028</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I’m on Zubsolv after treatment for ac/chronic pain using Fentanyl patches for 10 years. What would I use for pain once I was treated at an ANR facility?</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(90,'2020-12-23 18:10:34','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Daniel Tolocko','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Daniel Tolocko</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>October</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>26</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1982</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>white</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>white</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>st mary\'s Ascension</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>Mequon 262-243-6700</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>180</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5\'9\"</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>3249 w Oak Shore Lane</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Mequon</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Wisconsin</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>53092</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>414-305-1834</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>dtolocko@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Kelly Tolocko</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Wife</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>ktolocko@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>414-651-7773</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>I would like to keep the drug, drug amount, and drug usage between the doctor and myself.  My wife knows I have a problem but not to the extent.  I am a quiet person and don\'t talk about my drug of choice or usage with her.  </td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Heroin</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>1/2 -1 gram </td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>snort nasely</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>clinic and at home</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>11/05/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>36-48 hour marker I start to get nauseous.  Typical hot and cold flashes, strange thoughts delirious.  Mostly bedridden.  </td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>Haven\'t been \'clean\' since 2015 for 6-7 months and still had caving\'s.</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>suboxone 2-3 years total.  At separate times. </td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>It was mandatory with the suboxone treatment. </td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>an antidepressant to help sleep </td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>.5mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>1 at night before bed</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>xanax</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>.25-.5 mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>on average 1 or 2 a week </td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>suboxone</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>8mg-16mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>when detoxing </td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(91,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>3 failed login attempts (0 lockout(s)) from IP <b>35.189.223.35</b> and it was blocked for 20 minutes<br>Last user attempted: <b>[login]</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(92,'2020-12-23 18:16:17','45.79.210.65','chris.dread.94@facebook.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Christopher Dread</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>chris.dread.94@facebook.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7165336821</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>I am addicted to crack and alcohol and I smoke marijuana when I can’t afford my crack. I have 3 children and I need help. My children’s mother is also an alcoholic </td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(93,'2020-12-23 18:16:17','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Christopher Dread - Contact Page','</p>\n<p>Christopher Dread</p>\n<p>chris.dread.94@facebook.com</p>\n<p>7165336821</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: chris.dread.94@facebook.com <chris.dread.94@facebook.com>','',NULL,'1.9.7'),(94,'2020-12-23 20:24:48','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Joseph Burridge</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>burridgejoseph1@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7813850858</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I\'ve been on suboxone for 9 years and I can\'t get off them</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: burridgejoseph1@gmail.com <burridgejoseph1@gmail.com>','',NULL,'1.9.7'),(95,'2020-12-23 20:24:48','45.79.210.65','burridgejoseph1@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Joseph Burridge</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>burridgejoseph1@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7813850858</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I\'ve been on suboxone for 9 years and I can\'t get off them</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(96,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>34.64.218.102</b> and it was blocked for 20 minutes<br>Last user attempted: <b>[login]</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(97,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>95.178.152.81</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(98,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>95.178.152.81</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(99,'2020-12-24 02:05:45','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fsdfs fdsfsd fsfsds','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fsdfs fdsfsd fsfsds</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>February</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>16</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>fsdfsdf343434fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>432</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fsdfd</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>10</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>direct</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>adhya clinic</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/31/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>dasdsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td>dadad</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>12</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>daily</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>rewrwe</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsfsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>fsdfsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>fsdfsdfsf</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(100,'2020-12-24 02:23:40','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fdgdf gdfgdf gdfgdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fdgdf gdfgdf gdfgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>September</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>20</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>543dgdfgdferte43534</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>dsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>43242</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>42342</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>fdfsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>fsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rakesh.gupta@salesforce.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>fsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsdfs fsdfs fsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsfsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>100</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>wewdsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/25/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>sdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>fsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>432</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>32</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>fsdfsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(101,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>188.162.14.120</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(102,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>188.162.14.120</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(103,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>186.94.50.200</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(104,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>186.94.50.200</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(105,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>170.79.168.130</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(106,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>170.79.168.130</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(107,'2020-12-24 07:03:51','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - test patient test last name','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>test patient test last name</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>February</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>1</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>3434234rwer</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>sdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>dsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>123</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>343</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>dfsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>74136</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>543534534</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>IT</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fdsfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdfdsfds</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>10</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Direct</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/17/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>dsadasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>dasdad</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>dasdad</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>dasdad</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>das</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>dsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>das</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(108,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>88.225.1.21</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(109,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>88.225.1.21</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(110,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>85.135.153.3</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(111,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>85.135.153.3</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(112,'2020-12-24 10:34:40','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Chris Gardner','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Chris Gardner</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>Chrisg@paintritepros.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9164792921</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>I would like to learn more about your program to see if it\'s the right program for me to help me kick Norcos</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(113,'2020-12-24 11:42:20','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Jacqueline','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Jacqueline</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>j72saddler@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8642661901</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>I like to know how this work and if is any bad side affect. The price for this treatment. The help is for my son.</p>\n</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(114,'2020-12-24 15:22:20','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Travis McAllister','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Travis McAllister</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>April</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>11</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1987</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>006846980</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>White</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>American </td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Walgreens</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>Boynton beach/ 561-736-3558</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>Dr kelso </td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>5617283134</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>195</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5’ 11”</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>3646 Oberon Ave</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Boynton Beach</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>FL</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>33436</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>5615131579</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>travis@razedesigns.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Casie mcallister</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Wife </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>travis@razedesigns.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>3525518943</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>Suboxone detox</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Suboxone</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>8mg</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Oral</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Immersion detox</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/15/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>I can’t stop alone. I get sick and cravingsi</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>1 month</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Gallbladder removal March 15, 2020</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>March 15 l, 2020 gallbladder surgery</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Gallbladder </td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>Skate board crash April 2020</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(115,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>176.118.111.133</b> and it was blocked for 20 minutes<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(116,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>176.118.111.133</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(117,'2020-12-24 17:48:00','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>carol crosson</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>seedjar@aol.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8564295303</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Withdrawing from oxycodone ,long and short acting.</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: seedjar@aol.com <seedjar@aol.com>','',NULL,'1.9.7'),(118,'2020-12-24 17:48:01','45.79.210.65','seedjar@aol.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>carol crosson</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>seedjar@aol.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8564295303</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>Withdrawing from oxycodone ,long and short acting.</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(119,'2020-12-24 19:00:00','45.79.210.65','ctapia505@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Cesaria Padila</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>ctapia505@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>5057956155</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>I have 34 year old son who has been addicted to one thing or another for over 15 years.  He nearly overdosed on heroin today.  Is he a candidate for your treatment?</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(120,'2020-12-24 19:00:00','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Cesaria Padila - Contact Page','</p>\n<p>Cesaria Padila</p>\n<p>ctapia505@gmail.com</p>\n<p>5057956155</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: ctapia505@gmail.com <ctapia505@gmail.com>','',NULL,'1.9.7'),(121,'2020-12-24 20:07:32','45.79.210.65','bperry129@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Brad Perry</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>bperry129@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>6314042133</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Hi,<br />\nI am addicted to heroin. I come from a great family, I have a great job, idk why I ever got started with this stuff but I need my old life back. I have tried many times to stop and I am just having the hardest time. Your treatment sounds amazing! I only hope it will work for me. I\'d love to talk more about it and get started right away.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(122,'2020-12-24 20:07:32','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Brad Perry - Contact Page','</p>\n<p>Brad Perry</p>\n<p>bperry129@gmail.com</p>\n<p>6314042133</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: bperry129@gmail.com <bperry129@gmail.com>','',NULL,'1.9.7'),(123,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.228.143.87</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(124,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>104.143.92.62</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(125,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.228.143.90</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(126,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.228.143.87</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(127,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>104.143.92.62</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(128,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>43.228.143.86</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(129,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.228.143.90</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(130,'2020-12-24 22:44:44','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - sdas dasdas 25','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>sdas dasdas 25</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>November</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>18</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>dsa23432432</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>ddsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>43</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>43</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Kheda</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>shahharsh81190@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>sfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>132</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>direct</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>vcvcxv</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/18/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>vxcvxcvxc</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>vxvx</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>cvxcvxc</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>vcxvx</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td>vxcvxcv</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>vxcvx</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>vxcvx</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>dail</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>sfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>dffsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>sdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>fsdfsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fdsfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>fsdfsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(131,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>43.228.143.86</b> and it was blocked for 24 hours<br>Last user attempted: <b>admin</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(132,'2020-12-24 22:57:20','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fsdf fdsfs','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fsdf fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>September</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>17</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>fdsfe43543</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>englkish</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>sdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>43</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>4354</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fsdfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>dfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/23/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfsfsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(133,'2020-12-25 01:57:29','45.79.210.65','ishineorlando@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Jason</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>ishineorlando@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>14075554333</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>Hi,</p>\n<p>I\'d like to sign up.  What is the cost to do ANR for  Kratom?</p>\n<p>Thanks</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(134,'2020-12-25 01:57:29','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Jason - Contact Page','</p>\n<p>Jason</p>\n<p>ishineorlando@gmail.com</p>\n<p>14075554333</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: ishineorlando@gmail.com <ishineorlando@gmail.com>','',NULL,'1.9.7'),(135,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2a00:a040:194:1196:f15a:13ae:6188:d6ce</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(136,'2020-12-25 06:44:18','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - test first test last','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>test first test last</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>August</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>18</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>4234234234</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>sdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>dsadasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>dsadsadas</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>dsadasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>213</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>32</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>sadasd</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>dasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>dsadas</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>sdasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>dasdsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>dasdsada</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>23</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>dasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>adsda</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/23/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>das</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>das</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(137,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2a00:a040:194:1196:f15a:13ae:6188:d6ce</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(138,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>2804:431:cfce:a8b8:f065:4c57:8248:ed12</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(139,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>2804:431:cfce:a8b8:f065:4c57:8248:ed12</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(140,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>12 failed login attempts (3 lockout(s)) from IP <b>85.254.75.86</b> and it was blocked for 20 minutes<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(141,'2020-12-25 08:47:11','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - dfsdf fdsfsd fdsf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>dfsdf fdsfsd fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>November</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>8</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>dsadadad</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>dasdsad</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>dsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>dasdad</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>dasdad</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>423</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>34</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Kheda</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>dasdsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>dasdad dsda</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>dsadas</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>dsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>dsada</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>sdasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/17/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>dasdasdsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>dsadasdsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>dasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>dsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>dasad</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(142,'2020-12-25 08:53:23','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fsdf fsdfsd sfdsfsd fsdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fsdf fsdfsd sfdsfsd fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>November</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>8</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>dsade4e3432</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>fsdfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Widowed</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>332423</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>34</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Kheda</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>gayle@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>dasda</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>dasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>dasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>dsadasd</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>dfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>423</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>4324</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>dasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/24/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>dasdasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>dsadsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>dsadsa</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>das</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>dasd</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(143,'2022-10-01 17:56:14','45.79.210.65','contact@anrclinicus.com','[ANR Clinic - Advanced Opioid Treatment Center] Failed login attempts','<p>Hello,</p><p>16 failed login attempts (4 lockout(s)) from IP <b>85.254.75.86</b> and it was blocked for 24 hours<br>Last user attempted: <b>anrclinic</b></p><p>Under Attack? Learn more about <a href=\"https://www.limitloginattempts.com/am-i-under-attack/?from=plugin-lockout-email\">brute force attacks</a>. Have Questions? Visit our <a href=\"https://www.limitloginattempts.com/resources/?from=plugin-lockout-email\" target=\"_blank\">help section</a>.<br><a href=\"https://anrclinic.nirazo.me/wp-admin/options-general.php?page=limit-login-attempts&tab=settings\">Unsubscribe</a> from these notifications.</p><hr><p>This notification was sent automatically via <b>Limit Login Attempts Reloaded Plugin</b>.</p>','content-type: text/html','',NULL,'1.9.7'),(144,'2020-12-25 09:37:39','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Michael ','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Michael </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>jupiterfunn@yahoo.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8643571791</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>How much is treatment? I hv a daughter who is hopelessly addicted to heroin and it’s destroying my life</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(145,'2020-12-25 09:40:32','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - dasd dasda dasdsa das','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>dasd dasda dasdsa das</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>October</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>19</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>343werwe</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>rwerwe</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>rwer</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>rwerw</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>rwer</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>rwerw</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>rwer</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>543</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>3423</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>sdfds fdsf fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfs fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fdsfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>sdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/10/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(146,'2020-12-25 10:09:12','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fsdfs fdsfsd fsdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fsdfs fdsfsd fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>October</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>19</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>dsf343242</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>sfsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Divorced</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>3543</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>3454</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>gfdgfd</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>gdfgdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>gfdgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>gfdgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>gfdgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>gdfgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/17/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>gfdgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>gdfgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>gdfgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(147,'2020-12-25 10:21:07','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - sdf fdsfs fsdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>sdf fdsfs fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>February</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>16</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>5345dgdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>ggdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Widowed</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>4534</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5345</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>dgfd gdfgdf gdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>gdfgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>gdfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>sdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/24/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fdsfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Severe</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>dgdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>gdfg</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>gdfgdgdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>dgfgd</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(148,'2020-12-25 11:05:24','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fdsfsd fsdfsd fdsfsd fsdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fdsfsd fsdfsd fdsfsd fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>October</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>19</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>sdf345r3453</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Kheda</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>sdfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdfsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/24/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fddsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(149,'2020-12-25 12:06:42','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - Erica Green','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>Erica Green</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>September</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>4</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1991</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>423374519</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>English </td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Female</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Single</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>White</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>Caucasian </td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>Walmart</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>Madison, AL</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>N/A</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>138</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>5\'5</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>1004 Penthouse Dr </td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Birmingham </td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>AL</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>35205</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9316752697</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>ericagreen4519@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>2057197775</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>Unemployed </td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>Brian Curtis </td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>Friend </td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>bcurtis209@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>2057197775</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Heroin</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>1.5 Grams daily</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Snorting </td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Meth</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>.5 Grams daily</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Snort/Smoking</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>Xanex</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>2 1MG daily</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>Swallowing </td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>Pearson Hall </td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>08/13/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>I feel hopeless,  like I should just end everything because it\'s to much. I hate heroin. I\'m not this person. </td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Severe</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>If you mean when I run out, then desperation is a good word.</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>When I was a teen. For multiple psychological issues.</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td>2 years ago</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Tonsils and Adenoids removed; tubal ligation; D&C for miscarriages (3); endometriosis treatment</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td>Severe vomiting,  reactive airway disease </td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>(2010) car accident that was severe </td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>In car accident and from severe abuse</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td>\"\"</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>Not diagnosed but I know I do.</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>Drug related </td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td>Drug related </td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(150,'2020-12-25 13:26:37','45.79.210.65','AdamRudder27@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">:</td>\n<td>Adam Rudder </td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>AdamRudder27@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>5023903237</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>US</td>\n</tr>\n<tr>\n<td valign=\"top\">:</td>\n<td>I\'m going through opiod withdrawal and need help.</td>\n</tr>\n<tr>\n<td valign=\"top\">Select:</td>\n<td>Search Engine</td>\n</tr>\n<tr>\n<td valign=\"top\">Hidden:</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(151,'2020-12-25 13:26:37','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com','New message from Adam Rudder  - Contact Page','</p>\n<p>Adam Rudder </p>\n<p>AdamRudder27@gmail.com</p>\n<p>5023903237</p>\n<p>US</p>\n<p></p>\n</p>\n<p></p>\n<p></p>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: AdamRudder27@gmail.com <AdamRudder27@gmail.com>','',NULL,'1.9.7'),(152,'2020-12-25 15:43:24','45.79.210.65','contact@anrclinicus.com,\\nben@anrclinicus.com','New Landing Page Form Submission','<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Tamaara Bouie</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>tamaara58@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7344108470</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I am on methadone and I  want to get off of it what is ANR</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>,\\nReply-to: tamaara58@gmail.com <tamaara58@gmail.com>','',NULL,'1.9.7'),(153,'2020-12-25 15:43:24','45.79.210.65','tamaara58@gmail.com','Submission Confirmation ','<p>Thank you for contacting us – we will get back to you soon.</p>\n<table>\n<tr>\n<td valign=\"top\">Name:</td>\n<td>Tamaara Bouie</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>tamaara58@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7344108470</td>\n</tr>\n<tr>\n<td valign=\"top\">Message:</td>\n<td>I am on methadone and I  want to get off of it what is ANR</td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(154,'2020-12-25 18:55:13','45.79.210.65','waismannben@gmail.com,\\ngal@bemedia.co.il','New message from  - Landing Page - Lori peranzo','<table>\n<tr>\n<td valign=\"top\">Full Name:</td>\n<td>Lori peranzo</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>peranzolori@gmail.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>7075627085</td>\n</tr>\n<tr>\n<td valign=\"top\">Paragraph Text:</td>\n<td>Would like info on blood detox for opiates. Don’t call today please - Christmas </td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(155,'2020-12-25 21:57:52','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - dsfds fdsff fsdf','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>dsfds fdsff fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>May</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>15</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>fdsf3435</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>dsfdsg</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Widowed</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>gsdg</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>gsdgsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>gsdgs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>gdsgs</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>gdsgfdg</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>123</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>345</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>asdasdas</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fsdfdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsdfs f sdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fsdfs f sf</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdfsd fsdf </td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>123</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/18/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Moderate</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(156,'2020-12-25 22:18:36','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - asda dsad  dsadas dsad','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>asda dsad  dsadas dsad</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>April</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>17</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>sdasd3423</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>dsfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>12</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>34</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>rakesh.gupta@salesforce.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>fdsfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>fdsfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/16/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>fdsfdsfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td>fsdfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>Yes</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),(157,'2020-12-25 22:28:30','45.79.210.65','ben@anrclinicus.com,\\ncontact@anrclinicus.com,\\nwaismannben@gmail.com,\\nolgamedowska@gmail.com','New Form Submission - Questionnaire - fsd f sdf sdf latest','</p>\n<table>\n<tr>\n<td valign=\"top\">HTML:</td>\n<td>\n<h3>Patient Information</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name:</td>\n<td>fsd f sdf sdf latest</td>\n</tr>\n<tr>\n<td valign=\"top\">Date of Birth:</td>\n<td>\n<h4>Date of Birth</h4>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Month:</td>\n<td>March</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Day:</td>\n<td>17</td>\n</tr>\n<tr>\n<td valign=\"top\">DOB - Year:</td>\n<td>1900</td>\n</tr>\n<tr>\n<td valign=\"top\">Social Security #:</td>\n<td>fdsfe34</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Language:</td>\n<td>rwere</td>\n</tr>\n<tr>\n<td valign=\"top\">SEX:</td>\n<td>\n<h3>Sex</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">MARITAL STATUS:</td>\n<td>\n<h3>Marital Status</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Sex:</td>\n<td>Male</td>\n</tr>\n<tr>\n<td valign=\"top\">Marital Status:</td>\n<td>Married</td>\n</tr>\n<tr>\n<td valign=\"top\">Race:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Ethnicity:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Preferred Pharmacy:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Location:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Care Doctor:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Weight:</td>\n<td>123</td>\n</tr>\n<tr>\n<td valign=\"top\">Height:</td>\n<td>3432</td>\n</tr>\n<tr>\n<td valign=\"top\">Address:</td>\n<td>\n<h3>Address</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Street:</td>\n<td>holi chakla</td>\n</tr>\n<tr>\n<td valign=\"top\">City:</td>\n<td>Nadiad</td>\n</tr>\n<tr>\n<td valign=\"top\">State:</td>\n<td>Gujarat</td>\n</tr>\n<tr>\n<td valign=\"top\">Zip:</td>\n<td>387001</td>\n</tr>\n<tr>\n<td valign=\"top\">Country:</td>\n<td>IN</td>\n</tr>\n<tr>\n<td valign=\"top\">Primary Phone:</td>\n<td>9974274528</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Alternate Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Occupation:</td>\n<td>sdfsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency Contact:</td>\n<td>\n<h3>Emergency Contact</h3>\n<p></p>\n<p>- Please list the person who will be accompanying you during treatment</p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">First and Last Name - Emergency:</td>\n<td>fsd fsd dfs </td>\n</tr>\n<tr>\n<td valign=\"top\">Relationship to Patient:</td>\n<td>sdfsdfsd</td>\n</tr>\n<tr>\n<td valign=\"top\">Email:</td>\n<td>harsh@bugendaitech.com</td>\n</tr>\n<tr>\n<td valign=\"top\">Phone:</td>\n<td>8128884151</td>\n</tr>\n<tr>\n<td valign=\"top\">Other Relevant Personal Remarks::</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">DRUGS CURRENTLY BEING USED:</td>\n<td>\n<h3>Drugs Currently Being Used</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Drug Name:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Amount Per Day:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Method of Use:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Most Recent Attempt to Withdraw:</td>\n<td>\n<h3>Most Recent Attempt to Withdraw</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Institution or Clinic:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Date:</td>\n<td>12/17/2020</td>\n</tr>\n<tr>\n<td valign=\"top\">General remarks about your withdrawal attempts:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>\n<h3>Craving scale while “clean\":</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Craving scale while “clean\"::</td>\n<td>Mild</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>\n<h3>Methadone or Suboxone Maintenance?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Methadone or Suboxone Maintenance?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">For How Long?:</td>\n<td>fsdfds</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>\n<h3>Have you ever received psychiatric treatment?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Have you ever received psychiatric treatment?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>\n<h3>Prior suicide attempts?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Prior suicide attempts?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">If so, when?:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Medical History:</td>\n<td>\n<h3>Past Medical History</h3>\n<p><i>Medication currently being used (other than drugs mentioned above)</i></p>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td>fdsf</td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td>fsdf</td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td>fsdfs</td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Medication:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Dose:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Frequency:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Route:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>\n<h3>Allergies (Medications, Food, etc.)?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Allergies (Medications, Food, etc.)?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify and describe reactions::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>\n<h3>Past Surgeries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Past Surgeries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>\n<h3>Hospitalization in the last two years?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Hospitalization in the last two years?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>\n<h3>Adverse reactions to anesthesia in the past?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Adverse reactions to anesthesia in the past?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>\n<h3>Emergency room visits in the last year?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Emergency room visits in the last year?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>\n<h3>Accidents? (work, car etc)</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Accidents? (work, car etc):</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>\n<h3>Head Injuries?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Head Injuries?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>\n<h3>Loss of consciousness?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>\n<h3>Seizures?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Loss of consciousness? Seizures?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>\n<h3>Heart disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Heart disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>\n<h3>Lung disease?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Lung disease?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>\n<h3>Liver disease / infections?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Liver disease / infections?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>\n<h3>Kidney disease / problem?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Kidney disease / problem?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify:</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>\n<h3>Diabetes?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Diabetes?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>\n<h3>Ulcers?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Ulcers?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>\n<h3>High Blood Pressure?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">High Blood Pressure?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>\n<h3>Asthma or shortness of breath?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Asthma or shortness of breath?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>\n<h3>Obstructive sleep apnea?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Obstructive sleep apnea?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please Specify::</td>\n<td></td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>\n<h3>Pregnancy?</h3>\n</td>\n</tr>\n<tr>\n<td valign=\"top\">Pregnancy?:</td>\n<td>No</td>\n</tr>\n<tr>\n<td valign=\"top\">Please specify :</td>\n<td></td>\n</tr>\n</table>\n<p></p>\n','Content-Type: text/html,\\ncharset=UTF-8,\\nX-Ninja-Forms:ninja-forms,\\nFrom: ANR Clinic - Advanced Opioid Treatment Center <contact@anrclinicus.com>','',NULL,'1.9.7'),