Carencia New Patient Form

Carencia New Patient Form | Part 2
Before We Begin

This is part 2 of 2. In order for your visit to be the best experience possible, please complete this form prior to your first visit.

Note: We recommend completing this form on your computer. If you have issues, please try the following:
- Clear your browser history/cookies.
- Check for browser updates
- Try viewing the website in private/incognito mode.
If you are having trouble with the form or have questions, please contact us at welcome@carencia.com.
Name of Patient (Enter the Same Name as Part 1)*

First NameLast Name
Date of Birth of Patient (Enter the Same Date of Birth as Part 1)*

MonthDayYear
Date
Email of Patient (Enter the Same Email as Part 1)*
example@example.com
Would you like to share your pharmacy information?

YesNo
Pharmacy
Pharmacy Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Phone Number
Fax Number
Fax Number

Medical History

Please list all the medications and supplements you currently take, including the dose, instructions, and the reason for taking.
Are you currently taking any medications and/or supplements?*

YesNo
Current Medications/supplements*
Do you have any drug allergies?*

YesNo
Drug Allergies*
Have you been diagnosed with a medical illness and/or have medical conditions?*

YesNo
Medical Illnesses*

Family History
Does your family have any history of medical conditions, mental health conditions or substance use?*

YesNo
Family History*
Your Signature*

Clear
Should be Empty:

Rows	None (None at all)	Slight (Rare, Less than a day or two)	Mild (Several Days)	Moderate (More than half the days)	Severe (Nearly Every Day)
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Feeling more irritated, grouchy, or angry than usual?
Sleeping less than usual, but still have a lot of energy?
Starting more projects than usual or doing more risky things than usual?
Feeling nervous, anxious, frightened, worried, or on edge?
Feeling panic or being frightened?
Avoiding situations that make you anxious?
Unexplained aches and pains?
Feeling that your illnesses are not being taken seriously enough?
Thoughts of actually hurting yourself?
Hearing things other people couldn't hear such as voices even when no one was around?
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
Problems with sleep that affect your sleep quality overall?
Problems with memory (e.g. learning new information) or location (e.g. finding your way home)?
Unpleasant thoughts urges, or images that repeatedly enter your mind?
Feeling driven to perform certain behaviors or mental acts over and over again?
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
Not knowing who you really are or what you want out of life?
Not feeling close to other people or enjoying your relationships with them?
Drinking at least 4 drinks daily of any kind of alcohol in a single day?

Carencia New Patient Form | Part 2