DEMO PREVIEW — This is a working preview of the Evolve Health online questionnaire. It is NOT a real medical intake. Do not enter real health information — nothing you type or upload is sent, saved or stored.
EVOLVE HEALTH
(940) 257-2002
Stop and get urgent care: Call 911 or go to the emergency department now for a headache that starts suddenly and reaches full intensity within seconds to a minute (thunderclap headache), the worst headache of your life, weakness, numbness, trouble speaking, vision loss, confusion, fainting, fever with a stiff neck, or a headache after a head injury — these can signal a serious emergency.
If you are having any of these symptoms right now, do not continue this form — call 911 or go to the emergency department.
Completing this form does not guarantee a prescription. A Texas Clinician reviews every case and decides whether treatment is safe and appropriate.

Step 1 of 13 — Eligibility gates

Are you having any urgent symptom listed above right now? *
I confirm each of the following (all must apply): *

Step 2 of 13 — About you

How may we contact you about this care? *
May we leave a generic voicemail (no medical details)? *

Step 3 of 13 — Identity verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart.
Photo of the FRONT of your government ID *
Demo only — files are never uploaded.
Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.
Photo of the BACK of your ID — the barcode side *
The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.
Selfie *
Look at the camera like a passport photo — no sunglasses or hat.
Identity confirmation *

Step 4 of 13 — Verified prior diagnosis gate

This online form is for refill and continuation care for migraine that has already been diagnosed and verified. If migraine has not been diagnosed for you before, if your headache pattern has changed, or if this would be your first time starting a triptan, a live video visit comes first so the Clinician can evaluate you fully. You are welcome here either way — this gate simply chooses the safest starting point for your care.
Has a clinician previously diagnosed you with migraine? *
Have you ever had brain imaging (CT or MRI) or other testing for your headaches? *
Since your diagnosis, has your headache pattern changed in any of these ways?
May we request records from the clinician who diagnosed your migraine, if needed to verify your diagnosis? *
The Clinician reviews the information you provide here, including your prior diagnosis details and prescription history. If verification is not possible from your answers, the Clinician will convert your case to a video visit before any prescription decision.

Step 5 of 13 — Headache diary and frequency

Your recent headache pattern helps the Clinician confirm that refill care is still the right fit. Answer for the past 3 months as best you can.
How long does a typical migraine attack last without treatment? *
How severe is a typical attack at its worst? *
During a typical attack, check all symptoms you have:
Known triggers (check any):

Step 6 of 13 — Aura capture

Some people have warning symptoms called aura before or during a migraine — for example, flashing lights, zigzag lines, blind spots, tingling or numbness, or trouble finding words. Aura details matter for medication safety, so please answer carefully.
Before or during your migraines, do you ever have visual changes such as flashing lights, zigzag lines, shimmering spots, or blind spots? *
Do you ever have tingling, pins-and-needles, or numbness (face, hand, arm, or leg) before or during a migraine? *
Do you ever have trouble speaking or finding words before or during a migraine? *
Do you ever have weakness on one side of your body before or during a migraine? *
Is your aura new, different, or longer than it used to be? *

Step 7 of 13 — Red-flag exits

The symptoms and situations below need in-person or emergency evaluation, not online refill care. Checking any one of them stops this form and shows you the safest next step — your care team will still help you get to the right place.
Check YES for any that apply to you now or with your recent headaches:

Step 8 of 13 — Triptan and cardiovascular safety screen

Triptans are a common migraine medicine, and they are not safe for everyone — in particular, they require extra caution with heart and blood-vessel conditions and certain other medicines. Answer honestly; a yes helps the Clinician choose a safe plan, which may include a video visit or a different treatment approach.
Check YES for any that apply to you:
Have you ever taken a triptan (for example sumatriptan, rizatriptan, eletriptan, or another -triptan)? *
Have you ever had chest pain, chest tightness, jaw or arm pain, severe dizziness, or a racing heartbeat after a migraine medicine? *
A recent blood pressure reading helps the Clinician review triptan safety. If you do not have a recent reading, most pharmacies will check it free. If a reading is needed and not provided, the Clinician may ask for one or convert your case to a video visit before deciding.
Do you have diabetes, high cholesterol, or a family history of heart disease before age 60? *

Step 9 of 13 — Medication-overuse screen and treatment history

Using headache medicines very often can itself cause more headaches — this is called medication-overuse headache. These questions help the Clinician spot that pattern and build a plan that gives you relief without overuse. Frequent headache-medicine use can drive more headaches. If your answers suggest overuse, the Clinician will convert your case to a video visit to build a safer plan with you before any refill decision.
Do you feel you need a headache medicine most days, or do headaches return as soon as a dose wears off? *
Which migraine treatments are you currently prescribed? Check all that apply.
Are you requesting a refill of the same medicine and dose you are already prescribed? *

Step 10 of 13 — Health history

Check every condition you have now or have had before:
Could you be pregnant, are you currently pregnant, or are you breastfeeding? *
Some migraine medicines need extra review during pregnancy or breastfeeding. The Clinician may convert your case to a video visit to choose the safest plan with you.
During the past 2 weeks, have you often felt down or depressed, or had little interest or pleasure in things? *
Are you currently thinking about harming yourself or someone else? *

Step 11 of 13 — Medicines and allergies

Have you had an allergic reaction or serious side effect to any migraine medicine? *

Step 12 of 13 — How you will receive medication

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.
Pharmacy pickup: *

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Step 13 of 13 — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; request records to verify your prior migraine diagnosis; ask you to confirm a recent blood pressure reading; schedule a video or in-person evaluation — including for a new diagnosis, a changed pattern, any neurologic symptom, a first triptan start, a medicine or dose change, or any cardiovascular safety flag; or recommend urgent, emergency, or primary care evaluation. No medicine is promised.
Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.
Type your full legal name to confirm each statement: *