</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>Michelle Marx</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>September</td>
</tr>
<tr>
<td valign="top">DOB - Day:</td>
<td>5</td>
</tr>
<tr>
<td valign="top">DOB - Year:</td>
<td>1969</td>
</tr>
<tr>
<td valign="top">Social Security #:</td>
<td></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>Female</td>
</tr>
<tr>
<td valign="top">Marital Status:</td>
<td>Single</td>
</tr>
<tr>
<td valign="top">Race:</td>
<td>White </td>
</tr>
<tr>
<td valign="top">Ethnicity:</td>
<td>White</td>
</tr>
<tr>
<td valign="top">Preferred Pharmacy:</td>
<td>Newport Coast </td>
</tr>
<tr>
<td valign="top">Location:</td>
<td>Newport </td>
</tr>
<tr>
<td valign="top">Primary Care Doctor:</td>
<td>Dr. Wasbin </td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td></td>
</tr>
<tr>
<td valign="top">Weight:</td>
<td>135</td>
</tr>
<tr>
<td valign="top">Height:</td>
<td>55</td>
</tr>
<tr>
<td valign="top">Address:</td>
<td>
<h3>Address</h3>
</td>
</tr>
<tr>
<td valign="top">Street:</td>
<td>54 Lessay </td>
</tr>
<tr>
<td valign="top">City:</td>
<td>Newport Coast </td>
</tr>
<tr>
<td valign="top">State:</td>
<td>CA</td>
</tr>
<tr>
<td valign="top">Zip:</td>
<td>92657</td>
</tr>
<tr>
<td valign="top">Country:</td>
<td>US</td>
</tr>
<tr>
<td valign="top">Primary Phone:</td>
<td>94937646333</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>Mickyomarx@aol.com</td>
</tr>
<tr>
<td valign="top">Alternate Phone:</td>
<td>9492359826</td>
</tr>
<tr>
<td valign="top">Occupation:</td>
<td>Profesional Dog:Animal Behavioral </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>Nancy Marx </td>
</tr>
<tr>
<td valign="top">Relationship to Patient:</td>
<td>Parent</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>nanomarx2@gmail.com</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>9493764633</td>
</tr>
<tr>
<td valign="top">Other Relevant Personal Remarks::</td>
<td>My addiction is with opiates (Subutex for the last-3 years) I suffer from chronic pain and didn’t want to use painkillers. Xanax for anxiety and agoraphobia. Alcohol daily just to feel I can function and don’t want to HAVE to take ANYMORE XANAX. </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>Subutex</td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>4-6 mgs </td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Oral </td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td>Alcohol </td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>Every day</td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Oral </td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td>Xanax </td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>2-2 1/2 mgs daily </td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Oral </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>Betty Ford / Hoag Hospital </td>
</tr>
<tr>
<td valign="top">Date:</td>
<td>09/11/2015</td>
</tr>
<tr>
<td valign="top">General remarks about your withdrawal attempts:</td>
<td>left BFC after 36 days. Dr ... an ex drug addict himself told me I was ‘Med-seeking,’ later to find out I had 3 Large tumors in my cervix that desperately needed surgery. I had no choice but to leave. There’s obviously much more to this than I can text.<br />
The people in residential ‘college dormitory type places were using, ODing, microwaving turtles in their homes for entertainment.<br />
I was in so much pain from the tumors, I HAD TO leave. I was at my wits end and afraid for my life.</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>Moderate</td>
</tr>
<tr>
<td valign="top">Please Specify:</td>
<td>My past traumas have usually lead me to use a drug that would make me forget it and I could leave that reality asap. </td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>
<h3>Methadone or Suboxone Maintenance?</h3>
</td>
</tr>
<tr>
<td valign="top">Methadone or Suboxone Maintenance?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">For How Long?:</td>
<td>I’ve tried Methadone but never gave it a ‘real chance.’</p>
<p>Suboxone I couldn’t use without violent  effects from the ‘Naltrexone’ in it.<br />
Subutex seemed to help me control cravings, withdrawals and for a while helped me with my pain and I didn’t need to use pain meds. Now I feel that my body has changed and started to regret ever relying on it. I’ve had to regulate my use by going as far as I can without it And going back up in mgs to help withdrawal symptoms.</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>
<h3>Have you ever received psychiatric treatment?</h3>
</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>Rather talk to Licensed Psychiatrist than answer questions like this online. There’s just too much pain in my history  </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>Yes</td>
</tr>
<tr>
<td valign="top">If so, when?:</td>
<td>Again I don’t feel comfortable talking about this online. </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>Petroleum Jelly.</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>My right shoulder was smashed and had to be replaced with a metal plate and pins I believe that was done in 2016.<br />
Removal of three great size grapefruit sized tumor’s in my cervix area. All non cancerous.Benign. I have had a hysterectomy but I still have my ovaries.<br />
Had cysts removed from I believe my right breast but they were found To be benign.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Again another question that I would much rather speak to you in detail with a person then try to explain this online I am sorry thank you I really need your help though</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Ruptured appendix/appendicitis and major infection that had me taking IV antibiotics for over a month.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Abuse, accidentally ran into door and lost consciousness for a while.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Ran into a door and lost consciousness for an undetermined amount of time.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>I believe I had a seizure last year November 2020 because of Social drug use that turned out to be bad but I don’t know that to be a fact.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Elevated liver  enzymes and hepatitis see however I took medication that was supposed to stop it and it did for the most part as far as I know</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td>21?years old. Terminated pregnancy.</td>
</tr>
<tr>
<td valign="top">Hidden:</td>
<td>33281950.1609290752</td>
</tr>
<tr>
<td valign="top">Form record id:</td>
<td>0123t000000mitmAAA</td>
</tr>
<tr>
<td valign="top">Lead record type id:</td>
<td>0123t000000meiEAAQ</td>
</tr>
</table>
<p></p>
