</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>Audrey Storch</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>March</td>
</tr>
<tr>
<td valign="top">DOB - Day:</td>
<td>28</td>
</tr>
<tr>
<td valign="top">DOB - Year:</td>
<td>1959</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>Married</td>
</tr>
<tr>
<td valign="top">Race:</td>
<td>CAUCASIAN</td>
</tr>
<tr>
<td valign="top">Ethnicity:</td>
<td>JEWISH</td>
</tr>
<tr>
<td valign="top">Preferred Pharmacy:</td>
<td>TENS PHARMACY</td>
</tr>
<tr>
<td valign="top">Location:</td>
<td>ROSELAND, NJ 973-226-1200</td>
</tr>
<tr>
<td valign="top">Primary Care Doctor:</td>
<td>DR. LISA RAACKE</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>551-996-8111</td>
</tr>
<tr>
<td valign="top">Weight:</td>
<td>145</td>
</tr>
<tr>
<td valign="top">Height:</td>
<td>5'2"</td>
</tr>
<tr>
<td valign="top">Address:</td>
<td>
<h3>Address</h3>
</td>
</tr>
<tr>
<td valign="top">Street:</td>
<td>85 Four Seasons Drive</td>
</tr>
<tr>
<td valign="top">City:</td>
<td>NORTH CALDWELL</td>
</tr>
<tr>
<td valign="top">State:</td>
<td>NEW JERSEY</td>
</tr>
<tr>
<td valign="top">Zip:</td>
<td>07006</td>
</tr>
<tr>
<td valign="top">Country:</td>
<td>US</td>
</tr>
<tr>
<td valign="top">Primary Phone:</td>
<td>973-650-5793</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>astorch@huggstogo.com</td>
</tr>
<tr>
<td valign="top">Alternate Phone:</td>
<td>973-633-1242</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>Michael Storch</td>
</tr>
<tr>
<td valign="top">Relationship to Patient:</td>
<td>Spouse</td>
</tr>
<tr>
<td valign="top">Email:</td>
<td>mstorch@metrohydraulic.com</td>
</tr>
<tr>
<td valign="top">Phone:</td>
<td>973-464-9555</td>
</tr>
<tr>
<td valign="top">Other Relevant Personal Remarks::</td>
<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 />
down in the last 18 months but due to DEA and doctors fears with the DEA I am having trouble continuing detoxing.</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>Morphine 100mg</td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>2</td>
</tr>
<tr>
<td valign="top">Method of Use:</td>
<td>Oral</td>
</tr>
<tr>
<td valign="top">Drug Name:</td>
<td>Oxycodone 30mg</td>
</tr>
<tr>
<td valign="top">Amount Per Day:</td>
<td>Every 6 hours </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>1 as needed</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>N/A</td>
</tr>
<tr>
<td valign="top">Date:</td>
<td>12/22/2020</td>
</tr>
<tr>
<td valign="top">General remarks about your withdrawal attempts:</td>
<td>I am being very successful for the past 18 months. I do not have mental addiction at all. Only physical.<br />
Chronic pain is making it harder but i wish to get totally off all to see my baseline. If the doctor would<br />
allow me to continue my detox in a comfortable manner I would continue on my own but my previous pain<br />
management doctor of almost 20 years had to stop prescribing and the new one is incredibly difficult.</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></td>
</tr>
<tr>
<td valign="top">Please Specify:</td>
<td>Doesn't apply. I don't crave it. Only when I am in pain do I need it.</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>Yes</td>
</tr>
<tr>
<td valign="top">Have you ever received psychiatric treatment?:</td>
<td>Long time ago. For anxiety and during Breast cancer in 1995</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>Prevastatin</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>20mg</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>1 time </td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>oral</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td>Levothyroxine</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>50 mcg</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>1 time</td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>oral</td>
</tr>
<tr>
<td valign="top">Medication:</td>
<td>Liothyronine</td>
</tr>
<tr>
<td valign="top">Dose:</td>
<td>5 mcg</td>
</tr>
<tr>
<td valign="top">Frequency:</td>
<td>1 time</td>
</tr>
<tr>
<td valign="top">Route:</td>
<td>oral</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>ALL Anti inflammatories, Dairy anything liquid from a cow. Catapres</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>Bilateral Knee Replacement 2017, March 1.<br />
Gallbladder removal 2 yrs ago?<br />
Ovaries removed same time as gallbladder<br />
Breast cancer lumpectomy 1995<br />
Lymphnode Dissection 1995<br />
Neck Fused 2007</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Fell on Thanksgiving small tears in right shoulder.</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify:</td>
<td>Kidney stone in 1996</td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>
<h3>Diabetes?</h3>
</td>
</tr>
<tr>
<td valign="top">Diabetes?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td>gestational in 1990. Injected 3x a day.<br />
A1C is prediabetic last 10 years.</td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>
<h3>Ulcers?</h3>
</td>
</tr>
<tr>
<td valign="top">Ulcers?:</td>
<td>Yes</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td>Bacterial long time ago</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>Yes</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td>Rare but get reactive airway. Happened once this year<br />
once last year.</td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>
<h3>Obstructive sleep apnea?</h3>
</td>
</tr>
<tr>
<td valign="top">Obstructive sleep apnea?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please Specify::</td>
<td></td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>
<h3>Pregnancy?</h3>
</td>
</tr>
<tr>
<td valign="top">Pregnancy?:</td>
<td>No</td>
</tr>
<tr>
<td valign="top">Please specify :</td>
<td></td>
</tr>
</table>
<p></p>
