truForm: Online Medsys

Integration Field Count: 299 total fields integrate!

PATIENT INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

• Patient Name on the form must be split out into first name last name in order to integrate correctly.
• Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly. 
• Dentist/Doctor/Orthodontist/Referred By/Nearest Relative Names, on the form must be split out into first name last name in order to integrate correctly. 

1. Prefix
   
2. First Name
   
3. Middle Initial
   
4. Last Name
   
5. Gender
   
6. Birth Date
   
7. Age
   
8. Social Security Number
   
9. Email

10. Address Street Name
    
11. Apt 
    
12. City
    
13. State or Province
    
14. Zip or Postal Code
15. Home Phone
16. Cell Phone
17. Have you ever been a patient of our practice
18. Has a family member ever been a patient of our practice
19. Employer Name

20. Referred By First Name
    
21. Referred By Last Name
    
22. Dentist First Name
    
23. Dentist Last Name
    
24. Orthodontist First Name
    
25. Orthodontist Last Name
    
26. Doctor First Name
    
27. Doctor Last Name
    
28. Nearest Relative First Name
    
29. Nearest Relative Last Name
30. Nearest Relative Phone
31. Driver’s License
32. Payment Method

*IF YOU ARE USING A CUSTOM FORM: Emergency Name must be one field (can't be split into first name last name fields, or else it will not integrate). [See Example]

33. Emergency Full Name
    
34. Emergency Relation
    
35. Phone Home

RESPONSIBLE PARTY INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

• Responsible Name on the form must be split out into first name last name in order to integrate correctly.
• Responsible Address/ City/ State must be split out into its own fields in order to integrate correctly. 

36. First Name
    
37. Last Name
38. Relationship to Patient
    
39. Social Security Number
    
40. Date of Birth
    
41. Age
    
42. Phone Home
    
43. Phone Cell
    
44. Email Address

45. Address Street Name
    
46. Address Apt
    
47. City
    
48. State or Province
    
49. Zip or Postal Code
50. Driver's License
51. Employer Name
52. Phone Work

SPOUSE OR OTHER GUARANTOR INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

• Spouse or Guarantor Name on the form must be split out into first name last name in order to integrate correctly.
• Spouse or Guarantor address/ City/ State /Zip must be split out into its own fields in order to integrate correctly.

53. First Name
    
54. Last Name
55. Relation
56. Social Security Number
57. Date of Birth
58. Home Phone
59. Employer Name
60. Work Phone

61. Address Street Name
62. Apt
63. City
64. State or Province
65. Zip or Postal Code

SCHOOL AND INSURANCE INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

• School Name/ Address/ City/ State must be split out into its own fields in order to integrate correctly.

66. School Name
    
67. School Address Street Name
    
68. School City
    
69. School State or Province
70. School Zip or Postal Code

71. Student Status (Full, Part, Not)
72. Employed Status (Full, Part, Retired, Not)
73. Marital Status (Married, Divorced, Widow, Single, Legally Separated)
74. Do you belong to a PPO or HMO

INSURANCE INFORMATION

*IF YOU ARE USING A CUSTOM FORM: 

• Each insurance type (primary medical, primary dental, secondary medical, secondary dental must be separated into its own area for each question below in order to integrate correctly.
• All Address/ City/ State and Zip Codes must be split out into its own fields in order to integrate correctly.
• Insured Name on the form must be split out into first name last name in order to integrate correctly.

PRIMARY DENTAL

75. Insured Employer Name
    
76. Insured Employer Address
    
77. Insured Employer City
    
78. Insured Employer State or Province
    
79. Insured Employer Zip or Postal
    
80. Insured Employer Phone Number
    
81. Insured Policy Plan
    
82. Insured Insurance Company Name
    
83. Insured Policy ID
    
84. Insured Insurance Address Street
    
85. Insured Insurance City
    
86. Insured Insurance State or Province
    
87. Insured Insurance Zip or Postal Code
    
88. Insured Insurance Phone Number
    
89. Insured Policy Group Name
    
90. Insured Policy Group Number
    
91. Insured First Name
    
92. Insured Last Name
    
93. Insured Relation to Patient
    
94. Insured Date of Birth
    
95. Insured Gender
    
96. Insured Social Security Number
    
97. Insured Home Phone
    
98. Insured Home Address Street
    
99. Insured City
    
100. Insured State or Province
     
101. Insured Zip Code or Postal Code

SECONDARY DENTAL

129. Insured Employer Name
     
130. Insured Employer Address
     
131. Insured Employer City
     
132. Insured Employer State or Province
     
133. Insured Employer Zip or Postal
     
134. Insured Employer Phone Number
     
135. Insured Policy Plan
     
136. Insured Insurance Company Name
     
137. Insured Policy ID
     
138. Insured Insurance Address Street
     
139. Insured Insurance City
     
140. Insured Insurance State or Province
     
141. Insured Insurance Zip or Postal Code
     
142. Insured Insurance Phone Number
     
143. Insured Policy Group Name
     
144. Insured Policy Group Number
     
145. Insured First Name
     
146. Insured Last Name
     
147. Insured Relation to Patient
     
148. Insured Date of Birth
     
149. Insured Gender
     
150. Insured Social Security Number
     
151. Insured Home Phone
     
152. Insured Home Address Street
     
153. Insured City
     
154. Insured State or Province
     
155. Insured Zip Code or Postal Code

PRIMARY MEDICAL

102. Insured Employer Name
     
103. Insured Employer Address
     
104. Insured Employer City
     
105. Insured Employer State or Province
     
106. Insured Employer Zip or Postal
     
107. Insured Employer Phone Number
     
108. Insured Policy Plan
     
109. Insured Insurance Company Name
     
110. Insured Policy ID
     
111. Insured Insurance Address Street
     
112. Insured Insurance City
     
113. Insured Insurance State or Province
     
114. Insured Insurance Zip or Postal Code
     
115. Insured Insurance Phone Number
     
116. Insured Policy Group Name
     
117. Insured Policy Group Number
     
118. Insured First Name
     
119. Insured Last Name
     
120. Insured Relation to Patient
     
121. Insured Date of Birth
     
122. Insured Gender
     
123. Insured Social Security Number
     
124. Insured Home Phone
     
125. Insured Home Address Street
     
126. Insured City
     
127. Insured State or Province
     
128. Insured Zip Code or Postal Code

SECONDARY MEDICAL

156. Insured Employer Name
     
157. Insured Employer Address
     
158. Insured Employer City
     
159. Insured Employer State or Province
     
160. Insured Employer Zip or Postal
     
161. Insured Employer Phone Number
     
162. Insured Policy Plan
     
163. Insured Insurance Company Name
     
164. Insured Policy ID
     
165. Insured Insurance Address Street
     
166. Insured Insurance City
     
167. Insured Insurance State or Province
     
168. Insured Insurance Zip or Postal Code
     
169. Insured Insurance Phone Number
     
170. Insured Policy Group Name
     
171. Insured Policy Group Number
     
172. Insured First Name
     
173. Insured Last Name
     
174. Insured Relation to Patient
     
175. Insured Date of Birth
     
176. Insured Gender
     
177. Insured Social Security Number
     
178. Insured Home Phone
     
179. Insured Home Address Street
     
180. Insured City
     
181. Insured State or Province
     
182. Insured Zip Code or Postal Code

HEALTH HISTORY

*IF YOU ARE USING A CUSTOM FORM: 

• If you have a group of problems/issues in one question- they will not integrate.  They must be laid out similar to the format given below.

Some items we group together, will come over as one item, see below:

183. Reason for today's office visit
184. Are you in good health
185. Height
186. Weight
187. Have there been any changes in your general health in the past year
188. Are you under the care of a physician
189. If so, for what are you being treated
190. Date of last visit
191. Have you had any illness, operation or been hospitalized in the past five years
192. If so, describe
193. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth
194. If so, describe where
195. Do you have a prosthetic joint / implant
196. If so, describe where
197. Have you had a heart valve replacement or vascular graft
198. Have you ever had general anesthesia
199. Have you, or a family member, had any unusual or serious reactions to general anesthesia
200. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment
201. Rheumatic fever
202. Damaged heart valves / mitral valve prolapse
203. Heart murmur
204. High blood pressure
205. Low blood pressure
206. Chest pain / angina 
207. Heart Attack(s)
208. Irregular heart beat
209. Cardiac pacemaker
210. Heart surgery
211. Pneumonia, bronchitis, chronic  cough 
212. Asthma
213. Hay fever / sinus problems
214. Snoring
215. Sleep apnea / CPAP
216. Difficult breathing / other lung trouble
217. Tuberculosis

218. Emphysema
219. Do you smoke or vape  
220. If so, how much a day
221. Do you use chewing tobacco
222. Blood transfusion
223. Blood disorder such as anemia
224. Bruise easily
225. Bleeding tendency / abnormal bleed
226. Hepatitis, jaundice, or liver disease
227. Infectious mononucleosis
228. Gallbladder trouble
229. Fainting spells
230. Convulsions / epilepsy
231. Stroke
232. Thyroid trouble
233. Diabetes
234. Low blood sugar
235. Kidney trouble
236. High cholesterol
237. Are you on dialysis
238. Swollen ankles / arthritis / joint disease
239. Osteoporosis / osteopenia
240. Osteonecrosis
241. Stomach ulcers / acid reflux
242. Contagious diseases
243. Sexually transmitted diseases
244. Problems with immune system? Possibly from medication / surgery, etc.
245. Delay in healing
246. A tumor or growth
247. Cancer / radiation therapy / chemotherapy
248. Chronic fatigue / night sweats
249. Are you on a diet
250. A history of alcohol abuse
251. A history of marijuana or other drug use
252. Contact lenses
253. Eye disease / glaucoma
254. Mental health problems / anxiety / depression
255. A removable dental appliance
256. Pain or clicking of jaws when eating
257. Have you ever been the victim of mental or physical abuse?
258. Have you ever been diagnosed with PTSD? (post-traumatic stress disorder)?
259. Are you adopted or raised by someone other than your biological parents?
260. Are you presently or have you ever been under the care of a psychiatrist or admitted to a psychiatric mental health facility?

HEALTH HISTORY PERSONAL INFORMATION

257. If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours
258. Who is driving you home

259. Is there any condition concerning your health that the Doctor should be told about
260. If Yes, describe
261. Do you wish to speak to the Dr. privately about anything

WOMEN ONLY

262. Is there a possibility of pregnancy
263. Expected delivery date

264. Are you nursing
265. Are you taking birth control pills

MEDICATION

266. Any kind of medication, drug, pills
267. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)
268. Have you ever taken diet pills
269. Any natural product, herbal supplement or homeopathic remedy
270. Are you taking, or have you ever taken, bone density meds., RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV– Zometa, Aredia, Reclast or Evista in the past 12 years
271. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?
272. If so, please list

273. Please list any medications you are currently taking: (1-20)

DOES NOT INTEGRATE:

1. If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:
2. other description
3. treating doctor first name
4. treating doctor last name

ALLERGIES

274. Local anesthetic (numbing meds.)
275. Penicillin
276. Other antibiotics
277. Sulfa drugs
278. Sodium pentothal / Valium /other tranquilizers
279. Aspirin
280. Amoxicillin
281. Codeine or other narcotics
282. Latex
283. Soy
284. Eggs / yolk
285. Sulfites
286. Do you have any known allergies

287. Please list any allergies other than drug allergies
288. Please list any other medications or antibiotic you are allergic to
     • #1 medication/antibiotic name
     • #2 medication/antibiotic name
     • #3 medication/antibiotic name
     • #4 medication/antibiotic name
     • #5 medication/antibiotic name
     • #6 medication/antibiotic name
     • #7 medication/antibiotic name
     • #8 medication/antibiotic name
     • #9 medication/antibiotic name
     • #10 medication/antibiotic name

FAMILY HISTORY 

289. Family History of Cancer
290. Family History of Diabetes

291. Family History of Heart Disease
292. Family History of Anesthetic Problems

INJURY INFORMATION

293. Is this visit related to an accident
294. If Yes, what type of accident (auto/work related/other)
295. Date of injury

296. Insurance Company Handling Claim
297. Claim Number
298. Name of attorney / adjustor
299. Telephone number