</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>Jessa Fritzges</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>April</td>
</tr>
<tr>
<td valign="top">DOB - Day:</td>
<td>8</td>
</tr>
<tr>
<td valign="top">DOB - Year:</td>
<td>1981</td>
</tr>
<tr>
<td valign="top">Social Security #:</td>
<td>187684575</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>Cvs</td>
</tr>
<tr>
<td valign="top">Location:</td>
<td>6105307385</td>
</tr>
<tr>
<td valign="top">Primary Care Doctor:</td>
<td>Dr lyons</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>6104020101</td>
</tr>
<tr>
<td valign="top">Weight:</td>
<td>240</td>
</tr>
<tr>
<td valign="top">Height:</td>
<td>5’7”</td>
</tr>
<tr>
<td valign="top">Address:</td>
<td>
<h3>Address</h3>
</td>
</tr>
<tr>
<td valign="top">Street:</td>
<td>5736 Cetronia Rd</td>
</tr>
<tr>
<td valign="top">City:</td>
<td>Allentown</td>
</tr>
<tr>
<td valign="top">State:</td>
<td>Pennsylvania</td>
</tr>
<tr>
<td valign="top">Zip:</td>
<td>18106</td>
</tr>
<tr>
<td valign="top">Country:</td>
<td>US</td>
</tr>
<tr>
<td valign="top">Primary Phone:</td>
<td>6109721953</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>jessa.fritzges@gmail.com</td>
</tr>
<tr>
<td valign="top">Alternate Phone:</td>
<td>6105971549</td>
</tr>
<tr>
<td valign="top">Occupation:</td>
<td>Pet groomer</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>Linda uhrich</td>
</tr>
<tr>
<td valign="top">Relationship to Patient:</td>
<td>mother</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>lcuhrich@gmail.com</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>4846027402</td>
</tr>
<tr>
<td valign="top">Other Relevant Personal Remarks::</td>
<td>Please do not contact her until I know this is possible. Our relationship is complicated, she is also my landlord and could put me out of home and business. I may have to take my father or sister. </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>Fentanyl </td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>30 bags weening down</td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Injection</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>Pyramid</td>
</tr>
<tr>
<td valign="top">Date:</td>
<td>02/14/2020</td>
</tr>
<tr>
<td valign="top">General remarks about your withdrawal attempts:</td>
<td>Can’t take suboxen/subutex so they didn’t know what to do with me. Basically told me there was nothing they could do for after 12 days of throwing up bile. No food or even water could stay down. </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>Severe</td>
</tr>
<tr>
<td valign="top">Please Specify:</td>
<td>I have pain from Lyme and fibromyalgia </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>Tried methadone for maybe two years, couldn’t stop using</p>
<p>Did suboxen years ago...worked fine then when I tried to go back on it I had a severe reaction and they had to drill a hole into my bone marrow for fluids. I waited 3 full days before taking it. They think I’m allergic. </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>Yes</td>
</tr>
<tr>
<td valign="top">If so, when?:</td>
<td>20 years ago</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>Armour thyroid</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>240 mgs</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>1 daily</td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>Oral</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td>Clonazipam</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>2mgs</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>Twice daily</td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>Oral</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>Suboxen/subutex?</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>Total thyroidectomy<br />
Total adnoidectomy<br />
Bunionectomy left foot<br />
Lumpectomy back shoulderblade</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>Emergency dental extractions</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Over 7 years ago. No major injuries</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Hep c.... undetected<br />
Took holistic approach</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>
