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 trouble breathing, chest pain, confusion, fainting, severe pain, vomiting that will not stop, or a fever with shaking chills.

Get same-day in-person care instead of waiting for an online reply if you have a fever, pain in your back or side, vomiting, or blood in your urine — those signs mean this needs an in-person evaluation.

Completing this form does not guarantee a prescription. A Texas Clinician reviews every case and decides whether treatment is safe and appropriate. This online form is for women 18 and older with uncomplicated urinary symptoms only.

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 verified, online prescribing pauses: the Clinician may ask for a video visit to verify visually, or your care may be pickup-only if a prescription is approved after verification. The payment card used must be in your own name and match your ID.

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 — photo of your face *

Look at the camera like a passport photo — no sunglasses or hat.

Step 4 of 12 — Your current urinary symptoms

This section describes what you feel right now. Answer for this episode only. A clear symptom picture helps the Clinician decide whether online care fits, or whether in-person care will serve you better.
Which urinary symptoms do you have right now? Check all that apply. *
How bothersome are your symptoms today? *
Is the burning mainly outside, at the opening, rather than inside when urine passes? *
Burning felt mainly on the outside can point to a vaginal or skin cause rather than a bladder infection. The Clinician may recommend a video or in-person visit so the cause is treated correctly.
Do you have any vaginal discharge, itching, irritation, or odor that is new or different for you? *

Step 5 of 12 — Hard exclusion screen — uncomplicated cases only

Online UTI care covers uncomplicated cases only. Each item below needs an in-person evaluation, where an examination and urine testing can be completed the same day. Checking an item does not end your care — it routes you to the setting that can help you safely and promptly.
Check YES for any that apply to you right now: *
Have your symptoms lasted more than 7 days? *
Have you taken an antibiotic in the last 14 days, or for this episode? *
Could you be pregnant right now? *
Home pregnancy test *

Step 6 of 12 — Your UTI history

Have you had a UTI before? *
How was your last UTI confirmed? *
In the past 12 months, how many UTIs have you had (including this episode)? *
In the past 6 months, how many UTIs have you had (including this episode)? *
Have you ever had a kidney infection, a UTI that needed emergency or hospital care, or a UTI that did not clear with the first antibiotic? *
Do your symptoms often follow sexual activity, a new partner, or spermicide use?
Any concern about a sexually transmitted infection, or need for testing? *

Step 7 of 12 — Health history

Check every condition you have now or have had before: *
Are you currently breastfeeding, or did you give birth in the last 6 months? *

Step 8 of 12 — Medicines and allergies

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 and wellbeing

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? *
Do you feel safe at home and in your relationship(s)? *

Step 10 of 12 — Measurements and home test results

A reported fever routes to in-person care per the hard exclusion screen.

Recent labs we should know about *

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; ask you to take a pregnancy test or complete urine testing before deciding; request records or lab tests; schedule a video or in-person evaluation; 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.

Confirm each statement: *