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, trouble breathing, difficulty speaking, face or limb weakness, confusion, fainting, severe allergic reaction (swelling of the lips, tongue, or throat), or thoughts of harming yourself.
If you are already traveling and feel severely unwell, seek care where you are now — do not wait for an online reply.
Completing this form does not guarantee a prescription. A Texas Clinician reviews every case and decides whether treatment is safe and appropriate. Be exact about your departure date and time: honest timing protects you, because a medication that arrives or starts too late will not help your trip.

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.
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 12 — Your trip

Timing is part of safety and usefulness here. Give your real departure date and time, even if it is soon. If departure is too close for a medication to be started as directed, the Clinician will tell you plainly and offer pickup or in-person options instead — honest dates get you a plan that works.
How will you travel? Check all that apply.
What would you like help with? Check all that apply.
Will you be at high altitude, on a multi-day boat trip, or traveling somewhere with limited medical care? *
Is any part of this trip happening before a Clinician could reasonably review this form and a pharmacy could fill a prescription? Be honest — this changes the plan, and pickup may be the only workable route. *

Step 5 of 12 — Motion sickness history

Have you had motion sickness before? *
What triggers it for you? Check all that apply.
What symptoms do you get? Check all that apply.
How severe is it usually? *
Which motion sickness products have you used before? Check all that apply.
Do you also have migraine, vertigo, or an inner-ear condition? *
Dizziness and nausea with a new, changed, or neurologic pattern may need a video or in-person evaluation first, so the cause is understood before travel medication is considered.

Step 6 of 12 — Scopolamine safety screen

The scopolamine patch is a common motion sickness option, and it is not right for everyone. Answer honestly — a yes does not end your care; it helps the Clinician choose a safer option or a video visit.
Check YES for any that apply to you:
Age matters for this medication: older adults can be more sensitive to confusion, drowsiness, dry mouth, and trouble urinating. The Clinician weighs age together with the screen above. If the fit is uncertain, a video visit comes first.
Do you wear contact lenses, or do you have dry eyes that bother you?
Scopolamine can cause dry mouth, dry eyes, and blurred near vision. Handling a patch and then touching your eyes can dilate a pupil and blur vision — wash hands after handling, exactly as the Clinician and pharmacist direct.

Step 7 of 12 — Health history

Check every condition you have now or have had before:
Any surgery on your eyes, bladder, prostate, stomach, or bowel? *
Could you be pregnant right now, or are you breastfeeding? *

Step 8 of 12 — Medicines and allergies

Interaction safety depends on a complete list. Medicines and substances that cause drowsiness — including sleep aids, sedating antihistamines, anxiety or sleep medicines, pain medicines, and alcohol or cannabis — can add to the drowsiness of travel medicines. The Clinician reviews the full list before any decision.
Check any that apply to you:
Have you ever had a severe allergic reaction — swelling of the lips, tongue, or throat, trouble breathing, or a widespread rash or blistering? *

Step 9 of 12 — Lifestyle, wellbeing, and drowsiness counseling

Travel medicines, including scopolamine, can cause drowsiness, dizziness, dry mouth, and blurred vision. Until you know how a medication affects you: do not drive or operate machinery, take extra care with stairs, heights, boats, and swimming, and do not combine the medication with alcohol or sedating substances unless the Clinician has reviewed the combination. If you will be the driver, pilot, or boat operator on this trip, say so below — that changes what can be recommended.
Will you drive, pilot, operate a boat, or operate machinery during this trip? *
Drowsiness counseling agreement *
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 10 of 12 — Measurements and red-flag review

Red-flag check — check any you have right now:

Step 11 of 12 — 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 12 of 12 — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; request records or lab tests; schedule a video or in-person evaluation; explain that a request beyond motion sickness needs a different visit type; or recommend primary care, urgent care, or emergency evaluation. No medicine is promised.
Payment: your exact price is shown before checkout. Your card is authorized when you submit this form and The review fee is captured once the Clinician completes the review, whether or not treatment is approved. Medication, if prescribed, is separate. The card must be in your own name and match your ID.
Type your full legal name to confirm each statement: *