Rempli Practice — Patient Intake

📋 Intake for Rempli Practice — powered by Rempli

Want to auto-fill this form?Connect Epic MyChart →orConnect Oracle Health →

Rempli|Open Access Colonoscopy Screening Questionnaire

0% auto-filled from EHR

👤

Sections

Auto-filled from your health record

Saved from a previous form

From EHR — may be outdated

Please complete

You edited

🧑

Patient Information

Patient Name*

Patient DOB*

Phone Number*

Preferred Physician

📋

Screening Questions

Please answer the following screening questions.

Referring Provider

Current Height

Current Weight

Current Age

Are you currently taking any GLP-1 agonists medication? (ADLYXIN, BYDUREON BCISE, BYETTA, MOUNJARO, OZEMPIC, RYBELSUS, WEGOVY, VICTOZA, SAXENDA, TANZEUM, TRULICITY)*

NoYes

Are you currently on any blood thinners or diabetes medications?*

NoYes

If yes, name of the medication

Do you have any regular digestive symptoms (ex. Constipation, diarrhea, GERD)?*

NoYes

If yes, please list

Do you have any family history of colon cancer?*

NoYes

If yes, please list

Do you have any cardiac, respiratory, or kidney issues?*

NoYes

If yes, what type and the last time you saw the specialist

Any history of a pacemaker or implantable defibrillator?*

NoYes

Do you have any mobility restrictions?*

NoYes

If yes, are you wheelchair bound with the inability to self-transfer?

NoYes

Previous procedure or screening (colonoscopy, stool FIT or Cologuard)? When?

Preferred Pharmacy (name, telephone number, and address)

I confirm that the information on this form is accurate and authorize Rempli to share it with my healthcare provider. I understand my EHR data was accessed using my patient portal login and may be stored by Rempli to pre-fill future forms.