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 for chest pain or pressure, trouble breathing, coughing up blood, sudden weakness or numbness, trouble speaking, or vision changes.

If you are having thoughts of harming yourself, call or text 988 now — help is available right away, day or night.

Quitting smoking is one of the strongest steps you can take for your health, and support plus medication roughly doubles the chance of success. There is no judgment here: most people try more than once before quitting for good, and every attempt teaches us what will work for you.

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 12 — Eligibility gates

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

Step 2 of 12 — About you

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

Step 3 of 12 — 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. If your ID cannot be fully verified, any prescription is pickup only.

Prescriptions are picked up at your own pharmacy. If your ID cannot be verified, a video visit may be needed first.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Demo only — files are never uploaded.

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.

Step 4 of 12 — Your goal and quit date

What would you like help with? Check all that apply. *
If you have slipped or relapsed: that is a normal part of quitting, not a failure, and it does not change how we work with you. Tell us what happened and we will reset the plan together — a new quit date, a different aid, or extra support.

Step 5 of 12 — Smoking history

What do you currently use? Check all that apply. *
How soon after waking do you have your first cigarette? *
Do you find it hard not to smoke in places where it is not allowed, and do you smoke even when you are ill in bed? *
F5 and F6 help the Clinician gauge nicotine dependence and choose the right strength and type of quit aid.
What are your strongest triggers? Check all that apply. *
Does anyone in your household smoke? *
Are people close to you supportive of your quitting? *

Step 6 of 12 — Past quit attempts and aids used

How many times have you seriously tried to quit before? *
Every past attempt is useful information, not a setback. Most people who quit for good tried several times first — each attempt shows what helps you and what gets in the way.
Which quit aids have you used before? Check all that apply. *
Which aids are you open to trying this time? Check any. *
The Clinician makes the final recommendation after checking the safety screens below — some aids are not safe for some people, and that is exactly what the next sections are for.

Step 7 of 12 — Safety screens (these decide which aids are safe)

Varenicline and bupropion are not right for everyone. Answer honestly — a “yes” does not end your care; it helps the Clinician choose a safe aid, which may be nicotine replacement or a video or in-person visit instead.
Seizure and eating-disorder screen (important for bupropion — bupropion is not used when these apply): check YES for any that apply to you: *
Mood and mental-health screen (important for both bupropion and varenicline): check YES for any that apply to you: *
Varenicline counseling the Clinician will review with you: varenicline can cause nausea and unusually vivid dreams or sleep changes, and some people notice mood or behavior changes while taking it. If you are prescribed varenicline, stop and contact us the same day — or call/text 988 — if you notice new agitation, hostility, depressed mood, or thoughts of harming yourself. Avoid driving until you know how it affects you.
Kidney screen (varenicline dosing depends on kidney function): check YES for any that apply to you: *
Heart and blood-vessel screen: check YES for any that apply to you: *
Pregnancy screen: could you be pregnant, are you currently pregnant, or are you breastfeeding? *

Step 8 of 12 — Red-flag exit list

Some symptoms mean online care is not the right setting. If any of the following apply, stop and use the route shown — do not wait for an online reply.
Check any that apply to you right now: *

Step 9 of 12 — Health history

Check every condition you have now or have had before: *

Step 10 of 12 — Medicines, allergies, and wellbeing

Have you ever had a reaction to varenicline, bupropion, or a nicotine patch / gum / lozenge (for example a severe rash, swelling, mood change, or seizure)? *
Cannabis or other recreational substances? *
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 12 — How you will receive medication

If the Clinician prescribes, your prescription will be sent to your own pharmacy for pickup, and your insurance can pay for the medication there. Pickup is recommended for a first prescription: the pharmacy confirms your identity at the counter, which keeps the first fill safest. Some nicotine replacement products are also sold over the counter; the Clinician will tell you if an over-the-counter option is part of your plan. If your identity could not be verified in the identity section, pickup is the only option for this order.

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 12 of 12 — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; schedule a video or in-person evaluation — always the route during pregnancy, and whenever a safety screen needs a live conversation; recommend counseling or the free Texas quitline alongside medication; adjust your quit date so medication starts on the right schedule; or recommend primary care or emergency evaluation. No medicine is promised.

If you slip after quitting: message us and we will reset the plan — a new quit date, a different aid, or extra support. Slips are expected on the way to quitting for good and you will never be scolded for one here.

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.

Confirm each statement: *