Torch Questionnaire

We're sorry! This survey has been updated, and you'll need a new link. Please reach out to support@torchrx.com to get a new link to your intake survey.

Please answer every question honestly so your doctor can develop a safe and effective treatment plan based on your unique biology and needs.

Your doctor will contact you via our secure messaging portal once they’ve reviewed your intake form.

What is your birthday?* This field is required.Click the text field below and enter your birthday.

Date

How long have you been trying to lose weight?

My whole life

Several years

6-12 months

Less than 3 months

I haven't tried to lose weight in the past

Tell us a little about what you've tried previously to lose weight.

What is your ideal weight? (in lbs)

Why do you want to lose weight?

What is your biological sex?Your doctor needs this information to ensure the medication(s) they prescribe are tailored to and safe for you.

Female

Male

Are you pregnant, nursing, or trying to get pregnant in the near future?

Yes

Right now, Torch is only approved for people with certain BMIs. To calculate BMI, we need your height and weight.

To calculate your BMI, enter your weight & height:

The following questions will ask you about current and past health conditions.

Do you currently have any of the following conditions?If none apply, select None / NA.

None/NA

High cholesterol

Pre-diabetes

Joint pain

Sleep apnea

Fatty liver

Back pain

Arthritis

Nerve pain

Do you have high blood pressure?

YESNO

Are you receiving treatment for your high blood pressure?If you have high blood pressure and are not currently receiving treatment, we recommend you follow-up with your primary care doctor for further evaluation and monitoring.

Yes

Have you ever been diagnosed with, or treated for, any of the following medical conditions?Some of these conditions may put people at increased risk for health complications. Make sure to scroll all the way down and answer carefully. If none apply select None / NA.

None / NA

Anorexia or bulimia

Kidney or liver problems

Stroke

Coronary artery disease, heart failure, arrhythmia(s)

Brain Cancer

Suicide attempts / ideation

Glaucoma

Seizures

Chest pain

Cancer

Have you ever been treated for, or diagnosed with, any of the following medical conditions?Your doctor needs to know about your history with these conditions to select a weight loss medication that is safe and effective for you. If none apply, select None / NA.

None / NA

Type II Diabetes

Thyroid or other endocrine problems

Polycystic ovary disease (PCOS)

Bipolar disorder (manic depression)

History of depression

Migraine or severe headaches

Type I Diabetes

Lung disease

Have you ever been diagnosed with any other medical conditions? If so, please specify.

Over the last 2 weeks, how often have you been bothered by the following problems?

The following questions ask about current medications you’re taking that could impact which medication your doctor decides to prescribe you. Your doctor needs this information to prescribe a medication safest for you, so please be thorough and answer honestly.

Do you take any of the following medications?Your doctor needs this to select a weight loss medication that is safe and effect for you. Make sure to scroll all the way down. If none apply, select None / NA.

None / NA

Opioids

Methadone

Antipsychotics (such as clozapine, olanzapine, zotepine)

Amphetamines

Chemotherapies

Some medications interfere with others - is there anything on this list that applies to you?Your doctor needs this to select a weight loss medication that is safe and effect for you. Make sure to scroll all the way down. If none apply, select None / NA.

None / NA

Use of antidepressants

Use of seizure medications

Use, or recently used, any MAOIs

Use of medications that contain bupropion such as Wellbutrin, Aplenzin or Zyban

Use of dopaminergic medications

Recently and abruptly discontinued use of alcohol, benzos, barbituates, or antiepileptic drugs

Do you take any of the following medication types?These medications may contribute to weight gain, so your doctor will want to know if you're currently taking any of them. If you are not taking any listed medication(s), select None / NA.

None / NA

Beta blockers such as propranolol, atenolol, metoprolol

Blood pressure medication or medication for chest pain such as nifedipine, amlodipine, felodipine

Hormones such as glucocorticoids or estrogens

Mood stabilizers such as gabapentin, lithium, valproate, vigabatrin

HIV medications

Type I diabetes medications (such as insulin)

Type II diabetes medications (such as insulin or sulfonylureas)

Have you ever taken one/any of the following medications?

None/NA

Metformin

Byetta

Topiramate

Naltrexone

Zonisamide

Sulfonamide

Contrave

Wellbutrin

Bupropion

Zyban

Qsymia

Victoza

Saxenda

Orlistat (Alli or Xenical)

Please share details about your usage of these medications, including why they were prescribed, why you stopped taking this medication, and any changes, outcomes, or reactions to those medications.Your doctor may use this information to determine the right prescription, so please be thorough.

Please indicate if you would not want to take any of the following medicationsYour doctor may consider these medications as an option for weight loss otherwise.

None / NA

Metformin

Byetta

Topiramate

Naltrexone

Zonisamide

Sulfonamide

Contrave

Wellbutrin

Bupropion

Zyban

Qsymia

Victoza

Saxenda

Orlistat (Alli or Xenical)

Please provide some context for your doctor on why you would prefer to not take those medications.Any information you can provide will be helpful - concerns, hesitations, previous usage.

Please list all medications you currently take, with dosage, and any other medication history you think your doctor should know.If you are not currently taking medications, please continue.

Are you allergic to sulfanomide (i.e., sulfa-based meds)?

Yes

The next set of questions is about wellness, habits, and things you've tried in the past. We'll use this information to craft the right plan for you.

Which categories of food and beverages do you have difficulty limiting in your diet?

None / NA

Sweets (cookies, cake, ice cream, candy)

Salty snacks (chips, pretzels, salted nuts)

Fast food

Carbs (cereal, pastries, bread, granola bars)

Fried food (fries, fried chicken, onion rings)

Sugary drinks (soda, fruit juice, energy drinks)

Dairy products (milk, yogurt, cheese)

Processed meats (sausage, bacon, cold cuts)

Alcohol

Do you have a hard time with portion control?

Yes

When you have trouble controlling portions, are any of the following true?

I never feel full

I have a hard time stopping even though I feel full

Once I start eating something I feel as though I can’t stop

In which of the following circumstances do you overeat, or eat foods you are trying to avoid?

None / NA

At night, after dinner

When I’m lonely, anxious, or depressed

When I’m tired

When I’m under stress

When I’m bored or distracted (e.g. watching tv)

When I’m angry or frustrated

When I drink alcohol

When I’m socializing

When I’m around tempting foods and drinks (e.g. work, parties, family events)

How would you describe your sleeping habits?Sleep plays an integral role in weight management.

I get too much sleep ( > 9hrs / night)

I don’t get enough sleep ( < 7hrs / night)

I get a normal amount of sleep (7-9 hours / night)

Which option best describes your energy level?

I tend to be hyper and restless

I tend to be tired and lethargic

Neither applies

How much alcohol do you have each week?

None

1-5 drinks

5-10 drinks

>10 drinks

Are you willing to cut back on your alcohol consumption?

Yes

Do you smoke, or use other tobacco products? If so, please specify.

Do you take any recreational drugs? If so, please specify.

Do you have any allergies to medication or food? If so, please specify.

Have you ever had any surgeries? If so, please specify.

When was the last time you visited a primary care doctor?

0-6 months

6-12 months

12-18 months

2+ years

Have you had any bloodwork done in the last 6 months?

YESNO

Would you be willing to have your bloodwork done, if your doctor decides it's necessary to determine a prescription?

YESNO

To ensure the medication the doctor prescribes is safe and personalized, your doctor needs you to provide a recent (taken within the last 6 months) blood pressure reading.

If you don't have your blood pressure numbers today, finish the survey and get your blood pressure taken at the nearest pharmacy ASAP or call your doctor to get your latest reading.

Do you have a blood pressure reading (taken within the last 6 months) you can provide today?

Yes

What is your most recent blood pressure reading (within the past 6 months)?Blood pressure is always recorded as two numbers. The number on the top, known as systolic blood pressure, is always higher than the number on the bottom, known as diastolic.

Please present it the following way: (systolic / diastolic)

Finish the survey to completion. Then, get your blood pressure taken at the nearest pharmacy ASAP (almost all pharmacies do it for free).

Once you get a blood preasure reading send an email to: support@torchrx.com

Do you have a scale?We highly recommend purchasing a scale before beginning the Torch program to track your weight on a daily basis.

Yes

We need to make sure you are, well...you. To validate this, please take a photo of yourself, and of a government-issued ID. Make sure the pictures:
- Are well-lit and clear
- Are not blurry
- Are not cut off or incomplete

If you're having trouble submitting photos with the survey tool, go ahead and skip the photos by hitting 'NEXT' and 'SUBMIT' the survey without the photos. We'll get these from you later!

Please take a photo of yourself, and upload it here.Make sure we can see your face, shoulders, and upper body clearly: remove hats, glasses, and the photo should not have any other people in it.

Final step, take a clear photo of your government-issued ID.Make sure full name and DOB are clearly visible, all edges are showing, and the ID is a valid driver's license or passport.

Please hit SUBMIT below to complete the survey.

A doctor will review your information and decide what medication is safest, and ultimately the best fit for you. You can expect a message from your doctor within the next 3-5 business days.

We look forward to welcoming you to the Torch family!

Thank you! Hit submit to finish up!