Obsidian - Care Coordinator Intake

  • Welcome

  • You're a few minutes away from a personalized health review. Your answers go directly to your dedicated Care Coordinator, who will organize what you share into a clear summary and identify which Obsidian programs may match your goals. A licensed physician makes the final clinical decision before any prescription is issued.

    This intake takes about 12–15 minutes. Save and resume anytime.

    Care Coordinators are not licensed providers. They cannot diagnose conditions or prescribe medications.

  • Tell us about you

  • Format: (000) 000-0000.
  • Are you currently pregnant, breastfeeding, or actively trying to conceive?*
  • Last menstrual period (approximate)
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  • Can we send you text messages about your prescription, including tracking and refill information?*

  • Mobile information will not be sold or shared with third parties.

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  • Unfortunately we cannot service this condition in your state. Please contact your local physician for assistance.

  • Your state may require a phone or video consultation to complete your treatment. Don't worry! Your doctor will reach out to you if this is the case.

  • today*
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  • Sorry, you must be over 18 to use this service

  • Most of the therapies we offer aren’t appropriate during pregnancy or breastfeeding. We’ll keep your information and reach out after your delivery and breastfeeding period if you’d like. Reply to confirm.

  • Do you have any allergies or intolerances?*
  • Any medical conditions your doctor should know about?*
  • Are you taking any medications?*

  • Your goals & what you want to address

    Select everything that applies. Most people pick more than one.
  • Goals — what do you want to achieve? Choose all that apply.*
  • Problems — what are you currently dealing with? Choose all that apply.*

  • Lifestyle baseline

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  • Exercise frequency*
  • Exercise type*
  • Diet pattern*

  • A few more details

    Weight & Body Composition

  • Weight & Body Composition

  • Past weight-loss attempts. Select all that apply.*

  • Please uncheck "Never seriously tried" if you have other selections.

  • GLP-1 medication history*
  • GI sensitivity. Affects how we titrate GLP-1 medications*
  • Currently making active diet/exercise changes alongside considering medication?*

  • Performance & Athletic

  • Primary performance goal*
  • Drug-tested sports. This affects which therapies the licensed provider may consider — several peptides we offer are banned in tested sports.*

  • Sleep

  • Type of sleep issue. Select all that apply.*
  • Current sleep aids. Select all that apply.*

  • Please uncheck "None" if you have other selections.

  • Energy

  • Energy pattern*
  • Recent labs (CBC, CMP, ferritin, B12, vitamin D, TSH) in last 12 months?*
  • Known deficiencies. Select any that apply. Optional

  • Please uncheck "None known" if you have other selections.

  • Longevity

  • Aspects of aging that matter most*
  • Existing longevity practices

  • Please uncheck "Not yet" if you have other selections.

  • Sexual Health & Vitality

  • What aspect? Select all that apply.*
  • Onset*
  • Past PDE5 inhibitor use (Viagra, Cialis)*
  • Postmenopausal?*
  • Is your partner involved in this conversation, or is this just for you?*

  • Cognitive Performance

  • Type of cognitive concern. Select all that apply*
  • Onset*

  • Hormone Optimization

  • Low-T symptoms. Select all that apply*
  • Hormone labs*
  • Past TRT use*
  • Fertility goals. This determines whether to prioritize fertility-preserving options.*

  • Skin & Aesthetic

  • What aspect of skin? Select all that apply*
  • Daily SPF use*

  • Metabolic Health

  • Recent A1c known?*
  • Family history of diabetes*

  • Gut Health

  • Specific issue. Select all that apply*
  • Frequency*
  • Currently on a PPI / H2 blocker (Prilosec, Nexium, Pepcid, etc.)?*
  • Recent endoscopy or colonoscopy?*

  • Joint & Soft Tissue

  • Location(s). Select all that apply*
  • Acute or chronic?*
  • Pain medication use. Select all that apply

  • Please uncheck "None" if you have other selections.

  • Chronic Pain & Inflammation

  • Diagnosed condition. Select all that apply*
  • Are you currently taking any opioid pain medication (including tramadol)?*

  • Mood

  • Does your low mood seem to track with physical symptoms (pain, inflammation, fatigue)?*
  • Current antidepressant*

  • Anxiety & Stress

  • What kind of anxiety or stress are you dealing with? Select all that apply*
  • Currently on. Select all that apply*

  • Please uncheck "None" if you have other selections.

  • Need daytime non-sedating option?*

  • Immune Health

  • Pattern. Select all that apply*

  • Urinary Symptoms

  • Symptoms. Select all that apply.*
  • Currently on. Select all that apply*

  • Please uncheck "None" if you have other selections.

  • ID Verification: We'll need a clear picture of a valid ID or driver's license so we can make sure the data you provided is accurate.
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  • Did you understand all the questions which were asked?*

  • Do you want to share anything else with your health coordinator.

    • Ask any questions you have
    • List any medical problem you have which were not discussed above
    • Include anything else you would like the doctor to know.
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  • I have completed and submitted information through this form. I understand that the information I provide may be reviewed by authorized members of the care, support, or administrative team for the purpose of reviewing, processing, and responding to my submission.

    I confirm that the information I have provided is accurate and complete to the best of my knowledge. By submitting this form, I consent to accessing and reviewing the information I have shared.

  • Medications we offer:

  • Should be Empty: