ACTIVE 9/3 PPHS + DQs

1
Right now, Torch is only available for people with certain BMIs. To calculate BMI, we will need your weight and height.
2
To calculate your BMI, enter your weight and height:
3
Are you over 18 years of age? Standard question, we know, but definitely important for your care team.
YESNO
4
What was your assigned gender at birth?Your care team will use this information to ensure safe treatment.
Male
Female
5
Are you pregnant, nursing, or trying to get pregnant in the near future?Certain Torch programs are not recommended, if so.
YESNO
6
Do you believe healthy, sustained weight loss improves quality of life and overall well-being?
YESNO
7
How long have you been trying to lose weight?
Over a decade
A few years
6-12 months
Less than 6 months
I've never tried before
8
Of the following nutritional approaches, which have you tried to lose weight in the past?Select all that apply.
Calorie counting/restricting
Cutting out certain foods and/or food categories
Using a “food philosophy” like Keto, Whole 30, intermittent fasting, etc
Commercial weight loss program (e.g. Weight Watchers, Jenny Craig, or Nutrisystem etc)
Meal replacements
Other
None
9
Has anyone in your family struggled with their weight?
YESNO
10
Which of the following motivates you to lose weight?Select the one that is most relevant.
Improved quality of life
For my family/kids
Gain more energy
Increased confidence
Fit better in my clothes
Other
11
Do you take any of the following medications?* This field is required.Doctors use this information to ensure any/all prescriptions are safe and effective. The health of our members is our #1 concern. Select all that apply.
None/NA
Amphetamines
Opioids
Methadone
Antipsychotics (such as clozapine, olanzapine, zotapine)
12
Have you ever been diagnosed with, or treated for, any of the following conditions?* This field is required.Some of these conditions put certain individuals at increased risk for health complications. Doctors need this information to ensure prescriptions are an appropriate weight loss solution for Torch members. Select all that apply.
None/NA
Anorexia or bulimia
Kidney or liver problems
Stroke
Coronary artery disease, heart failure, arrhythmia(s),
Suicide attempts/ideation
Glaucoma
Seizures
Chest pain
13
Do you currently have any of the following conditions?If no, please select "None/NA"
None/NA
Pre-diabetes
High cholesterol
Joint pain
Sleep apnea
Fatty liver
Back pain
Arthritis
Nerve pain
14
Congratulations! You may qualify for Torch's program.* This field is required.Enter your email and click "submit" to view a limited time first month offer.
example@example.com
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