Rempli — Patient-Controlled EHR-to-Form

Auto-filled from your health record

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From EHR — may be outdated

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Patient Information

First Name*✓ From EHR

Middle Name✓ From EHR

Last Name*✓ From EHR

Date of Birth*✓ From EHR

Sex*✓ From EHR

Preferred Pronouns✓ From EHR

Marital Status✓ From EHR

Preferred Language✓ From EHR

Interpreter Needed?✓ From EHR

YesNo

Street Address✓ From EHR

Apt / Unit✓ From EHR

City✓ From EHR

State✓ From EHR

ZIP Code✓ From EHR

Home Phone✓ From EHR

Mobile Phone✓ From EHR

Email✓ From EHR

🚨

Emergency Contact

Name✓ From EHR

Relationship✓ From EHR

Phone✓ From EHR

Email✓ From EHR

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Insurance

Primary Insurance✓ From EHR

Policy Number✓ From EHR

Group Number✓ From EHR

Member ID✓ From EHR

Subscriber Name✓ From EHR

Subscriber DOB✓ From EHR

Secondary Insurance✓ From EHR

Leave blank if none

Secondary Policy Number✓ From EHR

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Reason for Visit

Chief Complaint / Reason for Visit*✓ From EHR

Current Symptoms

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Medical History

Active and past medical conditions

Problem List✓ From EHR

Condition

Status

Onset Date

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Surgical History

Past Surgeries & Procedures✓ From EHR

Procedure

Date

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Current Medications

Medications✓ From EHR

Medication

Dose

Route

Frequency

For

Status

⚠️

Allergies

Known Allergies✓ From EHR

Substance

Type

Reaction

Severity

Status

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Immunization History

Vaccines⚠️ EHR (may be outdated)

Vaccine

Date

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Family History

Family Medical History✓ From EHR

Include conditions of parents, siblings, and grandparents

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Social History

Occupation✓ From EHR

Employment Status✓ From EHR

Living Situation✓ From EHR

Tobacco Use✓ From EHR

Alcohol Use✓ From EHR

Recreational Drug Use✓ From EHR

Exercise / Activity✓ From EHR

Diet✓ From EHR

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Most Recent Vitals

From your last recorded visit. You can update these if they have changed.

Height✓ From EHR

Weight✓ From EHR

BMI✓ From EHR

Blood Pressure✓ From EHR

Heart Rate✓ From EHR

Temperature✓ From EHR

Oxygen Saturation✓ From EHR

Pain Score✓ From EHR

Measurement Date✓ From EHR

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Recent Lab Results

Most recent available results from your health record.

HbA1c✓ From EHR

Fasting Glucose✓ From EHR

Total Cholesterol✓ From EHR

LDL✓ From EHR

HDL✓ From EHR

Triglycerides✓ From EHR

Creatinine✓ From EHR

eGFR✓ From EHR

Hemoglobin✓ From EHR

Lab Date✓ From EHR

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.