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truForm: Online Medsys

Overview 

It is highly recommended by both Practice Advisory Group and PBHS that you utilize our PBHS Standard v.6 TruForm. 

This will ensure that every field from this standard form will integrate within Online Medsys Software.

If you choose to use your own custom form, please note any questions which are NOT present on our PBHS Standard v.6 TruForm will not integrate from your custom form within the software.  

Registration Process:

  1. Your TruForm link would be placed on your practice website for patients to complete online:  [ Preview HTML Form]

  2. Once the above form is submitted, your office would receive this completed PDF form [Preview PDF Form] which would integrate directly into your Online Medsys software!

*Please note, you will need to contact your software provider to obtain more information about the pricing for their TruForm bridge, as there may be additional fees.

 

Support

You can contact Online Medsys Support Below (for existing clients only):

Phone:

713-961-2723

Email:

support@omsp.com

Support Page:

[Click Here]

 

Integration Fields

This includes ALL fields that integrate between TruForm and Online Medsys.  If your custom form is setup correctly, items below will populate within your software. Note, if you have additional fields that are NOT listed below, you can manual enter them into your patients account once integration is completed!

If you use our standard form below, the sections listed below are already integrated!

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

  1. Address Street Name

  2. Apt 

  3. City

  4. State or Province

  5. Zip or Postal Code

  6. Home Phone

  7. Cell Phone

  8. Have you ever been a patient of our practice

  9. Has a family member ever been a patient of our practice

  10. Employer Name

  1. Referred By First Name

  2. Referred By Last Name

  3. Dentist First Name

     

  4. Dentist Last Name

  5. Orthodontist First Name

     

  6. Orthodontist Last Name

  7. Doctor First Name

  8. Doctor Last Name

  9. Nearest Relative First Name

     

  10. Nearest Relative Last Name

  11. Nearest Relative Phone

  12. Driver’s License

  13. 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]

  1. Emergency Full Name

  2. Emergency Relation

     

  3. 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. 

  1. First Name

     

  2. Last Name

  3. Relationship to Patient

     

  4. Social Security Number

     

  5. Date of Birth

  6. Age

  7. Phone Home

  8. Phone Cell

  9. Email Address

  1. Address Street Name

  2. Address Apt

  3. City

  4. State or Province

  5. Zip or Postal Code

  6. Driver's License

  7. Employer Name

  8. 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.

  1. First Name

  2. Last Name

  3. Relation

  4. Social Security Number

  5. Date of Birth

  6. Home Phone

  7. Employer Name

  8. Work Phone

  1. Address Street Name

  2. Apt

  3. City

  4. State or Province

  5. 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.

  1. School Name

     

  2. School Address Street Name

     

  3. School City

     

  4. School State or Province

  5. School Zip or Postal Code

  1. Student Status (Full, Part, Not)

  2. Employed Status (Full, Part, Retired, Not)

  3. Marital Status (Married, Divorced, Widow, Single, Legally Separated)

  4. 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

  1. Insured Employer Name

  2. Insured Employer Address

  3. Insured Employer City

  4. Insured Employer State or Province

  5. Insured Employer Zip or Postal

  6. Insured Employer Phone Number

  7. Insured Policy Plan

  8. Insured Insurance Company Name

  9. Insured Policy ID

  10. Insured Insurance Address Street

  11. Insured Insurance City

  12. Insured Insurance State or Province

  13. Insured Insurance Zip or Postal Code

  14. Insured Insurance Phone Number

  15. Insured Policy Group Name

  16. Insured Policy Group Number

  17. Insured First Name

  18. Insured Last Name

  19. Insured Relation to Patient

  20. Insured Date of Birth

     

  21. Insured Gender

     

  22. Insured Social Security Number

     

  23. Insured Home Phone

     

  24. Insured Home Address Street

     

  25. Insured City

     

  26. Insured State or Province

     

  27. Insured Zip Code or Postal Code

SECONDARY DENTAL

  1. Insured Employer Name

  2. Insured Employer Address

  3. Insured Employer City

  4. Insured Employer State or Province

  5. Insured Employer Zip or Postal

  6. Insured Employer Phone Number

  7. Insured Policy Plan

  8. Insured Insurance Company Name

  9. Insured Policy ID

  10. Insured Insurance Address Street

  11. Insured Insurance City

  12. Insured Insurance State or Province

  13. Insured Insurance Zip or Postal Code

  14. Insured Insurance Phone Number

  15. Insured Policy Group Name

  16. Insured Policy Group Number

  17. Insured First Name

  18. Insured Last Name

  19. Insured Relation to Patient

  20. Insured Date of Birth

     

  21. Insured Gender

     

  22. Insured Social Security Number

     

  23. Insured Home Phone

     

  24. Insured Home Address Street

     

  25. Insured City

     

  26. Insured State or Province

     

  27. Insured Zip Code or Postal Code

PRIMARY MEDICAL

  1. Insured Employer Name

  2. Insured Employer Address

  3. Insured Employer City

  4. Insured Employer State or Province

  5. Insured Employer Zip or Postal

  6. Insured Employer Phone Number

  7. Insured Policy Plan

  8. Insured Insurance Company Name

  9. Insured Policy ID

  10. Insured Insurance Address Street

  11. Insured Insurance City

  12. Insured Insurance State or Province

  13. Insured Insurance Zip or Postal Code

  14. Insured Insurance Phone Number

  15. Insured Policy Group Name

  16. Insured Policy Group Number

  17. Insured First Name

  18. Insured Last Name

  19. Insured Relation to Patient

  20. Insured Date of Birth

     

  21. Insured Gender

     

  22. Insured Social Security Number

     

  23. Insured Home Phone

     

  24. Insured Home Address Street

     

  25. Insured City

     

  26. Insured State or Province

     

  27. Insured Zip Code or Postal Code

SECONDARY MEDICAL

  1. Insured Employer Name

  2. Insured Employer Address

  3. Insured Employer City

  4. Insured Employer State or Province

  5. Insured Employer Zip or Postal

  6. Insured Employer Phone Number

  7. Insured Policy Plan

  8. Insured Insurance Company Name

  9. Insured Policy ID

  10. Insured Insurance Address Street

  11. Insured Insurance City

  12. Insured Insurance State or Province

  13. Insured Insurance Zip or Postal Code

  14. Insured Insurance Phone Number

  15. Insured Policy Group Name

  16. Insured Policy Group Number

  17. Insured First Name

  18. Insured Last Name

  19. Insured Relation to Patient

  20. Insured Date of Birth

     

  21. Insured Gender

     

  22. Insured Social Security Number

     

  23. Insured Home Phone

     

  24. Insured Home Address Street

     

  25. Insured City

     

  26. Insured State or Province

     

  27. 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:

  1. Reason for today's office visit

  2. Are you in good health

  3. Height

  4. Weight

  5. Have there been any changes in your general health in the past year

  6. Are you under the care of a physician

  7. If so, for what are you being treated

  8. Date of last visit

  9. Have you had any illness, operation or been hospitalized in the past five years

  10. If so, describe

  11. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth

  12. If so, describe where

  13. Do you have a prosthetic joint / implant

  14. If so, describe where

  15. Have you had a heart valve replacement or vascular graft

  16. Have you ever had general anesthesia

  17. Have you, or a family member, had any unusual or serious reactions to general anesthesia

  18. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment

  19. Rheumatic fever

  20. Damaged heart valves / mitral valve prolapse

  21. Heart murmur

  22. High blood pressure

  23. Low blood pressure

  24. Chest pain / angina 

  25. Heart Attack(s)

  26. Irregular heart beat

  27. Cardiac pacemaker

  28. Heart surgery

  29. Pneumonia, bronchitis, chronic  cough 

  30. Asthma

  31. Hay fever / sinus problems

  32. Snoring

  33. Sleep apnea / CPAP

  34. Difficult breathing / other lung trouble

  35. Tuberculosis

  1. Emphysema

  2. Do you smoke or vape  

  3. If so, how much a day

  4. Do you use chewing tobacco

  5. Blood transfusion

  6. Blood disorder such as anemia

  7. Bruise easily

  8. Bleeding tendency / abnormal bleed

  9. Hepatitis, jaundice, or liver disease

  10. Infectious mononucleosis

  11. Gallbladder trouble

  12. Fainting spells

  13. Convulsions / epilepsy

  14. Stroke

  15. Thyroid trouble

  16. Diabetes

  17. Low blood sugar

  18. Kidney trouble

  19. High cholesterol

  20. Are you on dialysis

  21. Swollen ankles / arthritis / joint disease

  22. Osteoporosis / osteopenia

  23. Osteonecrosis

  24. Stomach ulcers / acid reflux

  25. Contagious diseases

  26. Sexually transmitted diseases

  27. Problems with immune system? Possibly from medication / surgery, etc.

  28. Delay in healing

  29. A tumor or growth

  30. Cancer / radiation therapy / chemotherapy

  31. Chronic fatigue / night sweats

  32. Are you on a diet

  33. A history of alcohol abuse

  34. A history of marijuana or other drug use

  35. Contact lenses

  36. Eye disease / glaucoma

  37. Mental health problems / anxiety / depression

  38. A removable dental appliance

  39. Pain or clicking of jaws when eating

  40. Have you ever been the victim of mental or physical abuse?

  41. Have you ever been diagnosed with PTSD? (post-traumatic stress disorder)?

  42. Are you adopted or raised by someone other than your biological parents?

  43. 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

  1. If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours

  2. Who is driving you home

  1. Is there any condition concerning your health that the Doctor should be told about

  2. If Yes, describe

  3. Do you wish to speak to the Dr. privately about anything

 

WOMEN ONLY

  1. Is there a possibility of pregnancy

  2. Expected delivery date

  1. Are you nursing

  2. Are you taking birth control pills

 

MEDICATION

  1. Any kind of medication, drug, pills

  2. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

  3. Have you ever taken diet pills

  4. Any natural product, herbal supplement or homeopathic remedy

  5. 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

  6. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?

  7. If so, please list

  1. 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

  1. Local anesthetic (numbing meds.)

  2. Penicillin

  3. Other antibiotics

  4. Sulfa drugs

  5. Sodium pentothal / Valium /other tranquilizers

  6. Aspirin

  7. Amoxicillin

  8. Codeine or other narcotics

  9. Latex

  10. Soy

  11. Eggs / yolk

  12. Sulfites

  13. Do you have any known allergies

  1. Please list any allergies other than drug allergies

  2. 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 

  1. Family History of Cancer

  2. Family History of Diabetes

  1. Family History of Heart Disease

  2. Family History of Anesthetic Problems

 

INJURY INFORMATION

  1. Is this visit related to an accident

  2. If Yes, what type of accident (auto/work related/other)

  3. Date of injury

  1. Insurance Company Handling Claim

  2. Claim Number

  3. Name of attorney / adjustor

  4. Telephone number