</p>
<table>
<tr>
<td valign="top">HTML:</td>
<td>
<h3>Patient Information</h3>
</td>
</tr>
<tr>
<td valign="top">First and Last Name:</td>
<td>Steve Bright</td>
</tr>
<tr>
<td valign="top">Date of Birth:</td>
<td>
<h4>Date of Birth</h4>
</td>
</tr>
<tr>
<td valign="top">DOB - Month:</td>
<td>August</td>
</tr>
<tr>
<td valign="top">DOB - Day:</td>
<td>14</td>
</tr>
<tr>
<td valign="top">DOB - Year:</td>
<td>1964</td>
</tr>
<tr>
<td valign="top">Social Security #:</td>
<td>266-65-9495</td>
</tr>
<tr>
<td valign="top">Preferred Language:</td>
<td>English</td>
</tr>
<tr>
<td valign="top">SEX:</td>
<td>
<h3>Sex</h3>
</td>
</tr>
<tr>
<td valign="top">MARITAL STATUS:</td>
<td>
<h3>Marital Status</h3>
</td>
</tr>
<tr>
<td valign="top">Sex:</td>
<td>Male</td>
</tr>
<tr>
<td valign="top">Marital Status:</td>
<td>Married</td>
</tr>
<tr>
<td valign="top">Race:</td>
<td>Caucasian</td>
</tr>
<tr>
<td valign="top">Ethnicity:</td>
<td>Caucasian</td>
</tr>
<tr>
<td valign="top">Preferred Pharmacy:</td>
<td>Publix</td>
</tr>
<tr>
<td valign="top">Location:</td>
<td>Inverness, Florida 352-341-2602</td>
</tr>
<tr>
<td valign="top">Primary Care Doctor:</td>
<td>Ana C. Cruz-Diaz MD</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>352-765-3003</td>
</tr>
<tr>
<td valign="top">Weight:</td>
<td>160</td>
</tr>
<tr>
<td valign="top">Height:</td>
<td>5'6"</td>
</tr>
<tr>
<td valign="top">Address:</td>
<td>
<h3>Address</h3>
</td>
</tr>
<tr>
<td valign="top">Street:</td>
<td>3003 S. Jean Avenue </td>
</tr>
<tr>
<td valign="top">City:</td>
<td>Inverness</td>
</tr>
<tr>
<td valign="top">State:</td>
<td>Florida</td>
</tr>
<tr>
<td valign="top">Zip:</td>
<td>34450</td>
</tr>
<tr>
<td valign="top">Country:</td>
<td>US</td>
</tr>
<tr>
<td valign="top">Primary Phone:</td>
<td>352-302-2366</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>brightelec1@gmail.com</td>
</tr>
<tr>
<td valign="top">Alternate Phone:</td>
<td></td>
</tr>
<tr>
<td valign="top">Occupation:</td>
<td>Self Employed</td>
</tr>
<tr>
<td valign="top">Emergency Contact:</td>
<td>
<h3>Emergency Contact</h3>
<p></p>
<p>- Please list the person who will be accompanying you during treatment</p>
</td>
</tr>
<tr>
<td valign="top">First and Last Name - Emergency:</td>
<td>Teresa Bright</td>
</tr>
<tr>
<td valign="top">Relationship to Patient:</td>
<td>Wife</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>teresabright76@gmail.com</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>352-302-7349</td>
</tr>
<tr>
<td valign="top">Other Relevant Personal Remarks::</td>
<td></td>
</tr>
<tr>
<td valign="top">DRUGS CURRENTLY BEING USED:</td>
<td>
<h3>Drugs Currently Being Used</h3>
</td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td>Oxycotin</td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>3 - 30 mg. pills per day</td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>oral</td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td></td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td></td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td></td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td></td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td></td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td></td>
</tr>
<tr>
<td valign="top">Most Recent Attempt to Withdraw:</td>
<td>
<h3>Most Recent Attempt to Withdraw</h3>
</td>
</tr>
<tr>
<td valign="top">Institution or Clinic:</td>
<td>At Home</td>
</tr>
<tr>
<td valign="top">Date:</td>
<td>12/26/2020</td>
</tr>
<tr>
<td valign="top">General remarks about your withdrawal attempts:</td>
<td>Tried for two days, kept feeling worse and worse.  Made call to ANR Clinic, thinking this is best option.  read about other places and all they want to do is to give you pills and taper down or something like that.  I want to be drug free, I want to have my life back.  </td>
</tr>
<tr>
<td valign="top">Craving scale while “clean"::</td>
<td>
<h3>Craving scale while “clean":</h3>
</td>
</tr>
<tr>
<td valign="top">Craving scale while “clean"::</td>
<td>Mild</td>
</tr>
<tr>
<td valign="top">Please Specify:</td>
<td>Cravings are minimal at best, as long as I stay away from people that are doing it and not to have anything on hand or readily available.   </td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>
<h3>Methadone or Suboxone Maintenance?</h3>
</td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">For How Long?:</td>
<td></td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>
<h3>Have you ever received psychiatric treatment?</h3>
</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td></td>
</tr>
<tr>
<td valign="top">Prior suicide attempts?:</td>
<td>
<h3>Prior suicide attempts?</h3>
</td>
</tr>
<tr>
<td valign="top">Prior suicide attempts?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">If so, when?:</td>
<td></td>
</tr>
<tr>
<td valign="top">Past Medical History:</td>
<td>
<h3>Past Medical History</h3>
<p><i>Medication currently being used (other than drugs mentioned above)</i></p>
</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td></td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td></td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td></td>
</tr>
<tr>
<td valign="top">Route:</td>
<td></td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td></td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td></td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td></td>
</tr>
<tr>
<td valign="top">Route:</td>
<td></td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td></td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td></td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td></td>
</tr>
<tr>
<td valign="top">Route:</td>
<td></td>
</tr>
<tr>
<td valign="top">Allergies (Medications, Food, etc.)?:</td>
<td>
<h3>Allergies (Medications, Food, etc.)?</h3>
</td>
</tr>
<tr>
<td valign="top">Allergies (Medications, Food, etc.)?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Please specify and describe reactions::</td>
<td>Codeine, it gives me a rash all over.</td>
</tr>
<tr>
<td valign="top">Past Surgeries?:</td>
<td>
<h3>Past Surgeries?</h3>
</td>
</tr>
<tr>
<td valign="top">Past Surgeries?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td>Gallbladder removed ten years ago.</td>
</tr>
<tr>
<td valign="top">Hospitalization in the last two years?:</td>
<td>
<h3>Hospitalization in the last two years?</h3>
</td>
</tr>
<tr>
<td valign="top">Hospitalization in the last two years?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Adverse reactions to anesthesia in the past?:</td>
<td>
<h3>Adverse reactions to anesthesia in the past?</h3>
</td>
</tr>
<tr>
<td valign="top">Adverse reactions to anesthesia in the past?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Emergency room visits in the last year?:</td>
<td>
<h3>Emergency room visits in the last year?</h3>
</td>
</tr>
<tr>
<td valign="top">Emergency room visits in the last year?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Accidents? (work, car etc):</td>
<td>
<h3>Accidents? (work, car etc)</h3>
</td>
</tr>
<tr>
<td valign="top">Accidents? (work, car etc):</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Head Injuries?:</td>
<td>
<h3>Head Injuries?</h3>
</td>
</tr>
<tr>
<td valign="top">Head Injuries?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Loss of consciousness?:</td>
<td>
<h3>Loss of consciousness?</h3>
</td>
</tr>
<tr>
<td valign="top">Loss of consciousness?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Loss of consciousness? Seizures?:</td>
<td>
<h3>Seizures?</h3>
</td>
</tr>
<tr>
<td valign="top">Loss of consciousness? Seizures?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Heart disease?:</td>
<td>
<h3>Heart disease?</h3>
</td>
</tr>
<tr>
<td valign="top">Heart disease?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Lung disease?:</td>
<td>
<h3>Lung disease?</h3>
</td>
</tr>
<tr>
<td valign="top">Lung disease?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Liver disease / infections?:</td>
<td>
<h3>Liver disease / infections?</h3>
</td>
</tr>
<tr>
<td valign="top">Liver disease / infections?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Kidney disease / problem?:</td>
<td>
<h3>Kidney disease / problem?</h3>
</td>
</tr>
<tr>
<td valign="top">Kidney disease / problem?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td></td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>
<h3>Diabetes?</h3>
</td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>
<h3>Ulcers?</h3>
</td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">High Blood Pressure?:</td>
<td>
<h3>High Blood Pressure?</h3>
</td>
</tr>
<tr>
<td valign="top">High Blood Pressure?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Asthma or shortness of breath?:</td>
<td>
<h3>Asthma or shortness of breath?</h3>
</td>
</tr>
<tr>
<td valign="top">Asthma or shortness of breath?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>
<h3>Obstructive sleep apnea?</h3>
</td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>
<h3>Pregnancy?</h3>
</td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
<tr>
<td valign="top">Hidden:</td>
<td></td>
</tr>
<tr>
<td valign="top">Hidden:</td>
<td></td>
</tr>
<tr>
<td valign="top">Hidden:</td>
<td></td>
</tr>
</table>
<p></p>
