truForm: Henry Schein - Form Integration Fields

This includes ALL fields that integrate between TruForm v6 and Henry Schein v15.0+. If your custom form is setup correctly, items listed in this section will populate within your software.

Note, if you have additional fields that are NOT listed in this section, you can manual enter them into your patients account once integration is set!

If you use one of our standard forms below, the sections listed here are already integrated! 

• OMS STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• GD STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• ENDO/PERIO STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY

**Any fields listed in red, exist on our standard forms and DO NOT integrate. 

Integration Total Count:  187 Fields

This is the amount of fields from truForm that can integrate directly into the PMS of your patient's account.  

*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/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 (M/F)
   
6. Martial Description
   
7. Date of Birth
   
8. Age
   
9. Social Security Number
   
10. Home Phone
    
11. Cell Phone
    
12. Email
    
13. Driver’s License
    
14. Employer Name
    
15. Work Phone

16. Address Street Name
    
17. Apt
    
18. City
    
19. State or Province
    
20. Zip or Postal Code
21. Family member former patient?

*IF YOU ARE USING A CUSTOM FORM: Emergency Full Name should stay as one field for first and last name. 

22. Emergency Full Name 
    
23. Home Phone
    
24. Relation

25. Dentist First Name
    
26. Dentist Last Name
27. Orthodontist First Name
    
28. Orthodontist Last Name
29. Medical Doctor First Name
    
30. Medical Doctor Last Name
31. Referred By First Name
    
32. Referred By Last Name
33. Nearest Relative First Name
    
34. Nearest Relative Last Name
    
35. Nearest Relative Phone
36. Payment Method

DOES NOT INTEGRATE:

1. Did you find our practice online

*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 Party Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.  

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

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

*IF YOU ARE USING A CUSTOM FORM: 

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

54. First Name
    
55. Last Name
    
56. Relationship to Patient
    
57. Relationship Description
    
58. Date of Birth
    
59. Social Security Number

60. Address Street
    
61. Apt
    
62. City
63. State or Province
    
64. Zip Code or Postal Code
    
65. Home Phone
66. Employer Name
    
67. Work Phone

*IF YOU ARE USING A CUSTOM FORM:

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

68. School Name
    
69. School Address
70. School Street Name
    
71. School City
    
72. School State or Province
    
73. School Zip or Postal Code

74. School Status (Full, Part, Not)
75. Employer Status(Full, Part, Not)
    
76. PPO or HMO?

• 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 / Zip 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. 

IF THE INSURANCE COMPANY NAME FROM THE SUBMITTED TRUFORM DOESN'T 100% MATCH THE COMPANY NAME LISTED IN YOUR SOFTWARE, THIS ENTIRE INSURANCE SECTION WILL NOT INTEGRATE!
Henry Schein stance: There are so many variations on the insurance company names – if it isn’t an exact match, it could cause for multiple entries and a big mess.

PRIMARY DENTAL

2. Insured Relation to Patient
   
3. Insured First Name
   
4. Insured Last Name
   
5. Insured Gender (M/F)
   
6. Insured Date of Birth
   
7. Insured Social Security Number
   
8. Insured Home Phone
   
9. Insured Home Address Street
   
10. Insured City
    
11. Insured State or Province
    
12. Insured Zip Code or Postal Code
    
13. Insured Employer Name
    
14. Insured Employer Address
    
15. Insured Employer City
    
16. Insured Employer State or Province
    
17. Insured Employer Zip or Postal
    
18. Insured Employer Phone Number
19. Insured Policy Group Name
    
20. Insured Policy Group Number
    
21. Insured Policy ID
    
22. Insured Policy Plan
    
23. Insured Insurance Company Name
    
24. Insured Insurance Address Street
    
25. Insured Insurance City
    
26. Insured Insurance State or Province
    
27. Insured Insurance Zip/ Postal Code
    
28. Insured Insurance Phone Number

SECONDARY DENTAL

56. Insured Relation to Patient
    
57. Insured First Name
    
58. Insured Last Name
    
59. Insured Gender (M/F)
    
60. Insured Date of Birth
    
61. Insured Social Security Number
    
62. Insured Home Phone
    
63. Insured Home Address Street
    
64. Insured City
    
65. Insured State or Province
    
66. Insured Zip Code or Postal Code
    
67. Insured Employer Name
    
68. Insured Employer Address
    
69. Insured Employer City
    
70. Insured Employer State or Province
    
71. Insured Employer Zip or Postal
    
72. Insured Employer Phone Number
73. Insured Policy Group Name
    
74. Insured Policy Group Number
    
75. Insured Policy ID
    
76. Insured Policy Plan
    
77. Insured Insurance Company Name
    
78. Insured Insurance Address Street
    
79. Insured Insurance City
    
80. Insured Insurance State or Province
    
81. Insured Insurance Zip/ Postal Code
    
82. Insured Insurance Phone Number

PRIMARY MEDICAL

29. Insured Relation to Patient
    
30. Insured First Name
    
31. Insured Last Name
    
32. Insured Gender (M/F)
    
33. Insured Date of Birth
    
34. Insured Social Security Number
    
35. Insured Home Phone
    
36. Insured Home Address Street
    
37. Insured City
    
38. Insured State or Province
    
39. Insured Zip Code or Postal Code
    
40. Insured Employer Name
    
41. Insured Employer Address
    
42. Insured Employer City
    
43. Insured Employer State or Province
    
44. Insured Employer Zip or Postal
    
45. Insured Employer Phone Number
46. Insured Policy Group Name
    
47. Insured Policy Group Number
    
48. Insured Policy ID
    
49. Insured Policy Plan
    
50. Insured Insurance Company Name
    
51. Insured Insurance Address Street
    
52. Insured Insurance City
    
53. Insured Insurance State or Province
    
54. Insured Insurance Zip/ Postal Code
    
55. Insured Insurance Phone Number

SECONDARY MEDICAL

83. Insured Relation to Patient
    
84. Insured First Name
    
85. Insured Last Name
    
86. Insured Gender (M/F)
    
87. Insured Date of Birth
    
88. Insured Social Security Number
    
89. Insured Home Phone
    
90. Insured Home Address Street
    
91. Insured City
    
92. Insured State or Province
    
93. Insured Zip Code or Postal Code
    
94. Insured Employer Name
    
95. Insured Employer Address
    
96. Insured Employer City
    
97. Insured Employer State or Province
    
98. Insured Employer Zip or Postal
    
99. Insured Employer Phone Number
100. Insured Policy Group Name
     
101. Insured Policy Group Number
     
102. Insured Policy ID
     
103. Insured Policy Plan
     
104. Insured Insurance Company Name
     
105. Insured Insurance Address Street
     
106. Insured Insurance City
     
107. Insured Insurance State or Province
     
108. Insured Insurance Zip/ Postal Code
     
109. Insured Insurance Phone Number

*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:

77. Reason for today's office visit
78. Are you in good health
79. Weight
80. Height
81. Have there been any changes in your general health in the past year
82. Are you under the care of a physician 
83. If so, for what are you being treated?
84. Date of last visit
85. Have you had any illness, operation or been hospitalized in the past five years
86. If so, describe
87. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth 
88. If so, describe where
89. Do you have a prosthetic joint / implant  
90. If so, describe where
91. Have you had a heart valve replacement or vascular graft
92. Have you, or a family member, had any unusual or serious reactions to general anesthesia?
93. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
    
94. Rheumatic fever?
95. Damaged heart valves / mitral valve prolapse?
96. Heart murmur?
97. High blood pressure?
98. Low blood pressure?
99. Chest pain / angina?
    *Comes over as angina
100. Heart attack(s)?
101. Irregular heart beat?
102. Cardiac pacemaker?
103. Heart surgery?
104. Pneumonia, bronchitis, chronic cough? 
     *Comes over as bronchitis/chronic cough
105. Asthma?
106. Hay fever / sinus problems?
107. Snoring
108. Sleep apnea / CPAP?
109. Difficult breathing / other lung trouble?
     *Comes over as other lung trouble
110. Tuberculosis?
111. Emphysema?

112. Do you smoke or vape?
113. If so, how much a day
114. Do you use chewing tobacco?
     
115. Blood transfusion?
     
116. Blood disorder such as anemia?
     *Comes over as anemia
117. Bruise easily?
     
118. Bleeding tendency / abnormal bleed?
     *Comes over as bleeding tendency
     
119. Hepatitis, jaundice, or liver disease?
     
120. Infectious mononucleosis?
121. Gallbladder trouble?
     
122. Fainting spells?
     
123. Convulsions / epilepsy?
     
124. Stroke?
     
125. Thyroid trouble?
     
126. Diabetes?
     
127. Low blood sugar?
     
128. Kidney trouble?
     
129. High cholesterol?
     
130. Are you on dialysis?
     
131. Swollen ankles / arthritis / joint disease?
     *Comes over as arthritis)
     
132. Osteoporosis / osteopenia?
     
133. Osteonecrosis?
     
134. Stomach ulcers / acid reflux?
     *Comes over as stomach ulcers
     
135. Contagious diseases?
     
136. Sexually transmitted diseases?
     
137. Problems with immune system? Possibly from medication / surgery, etc.
     
138. Delay in healing?
     
139. A tumor or growth?
     
140. Cancer / radiation therapy / chemotherapy?
     *Comes over as x-ray or chemo
     
141. Chronic fatigue / night sweats?
     
142. Are you on a diet?
     
143. A history of alcohol abuse?
     
144. A history of marijuana or other drug abuse?
     
145. Contact lenses?
     
146. Eye disease / glaucoma?
     
147. Mental health problems / anxiety / depression
     *Comes over as mental health problems)
     
148. A removable dental appliance?
     
149. Pain or clicking of jaws when eating?

DOES NOT INTEGRATE:

110. Have you ever had general anesthesia?

This entire section will not integrate:

111. Is there a possibility of pregnancy?
     
112. Expected delivery date?
     
113. Are you nursing?
     
114. Are you taking birth control pills?

150. Any kind of medication, drug, pills?
151. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)?
152. Have you ever taken diet pills?
153. Any natural product, herbal supplement or homeopathic remedy?
154. Are you taking, or have you ever taken,
     bone density meds., RANKL inhibitors or bisphosphonates
     such as Denosumab, Fosamax, Boniva, Actonel, IV–
     Zometa, Aredia, or Evista in the past 12 years?

155. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list:
156. Please list any medication you are currently taking:
     (1-20 list, including medication name, dosage and frequency)**

DOES NOT INTEGRATE:    

115. 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: (other description & treating doctor first name/last name)

157. Local anesthetic (numbing meds.)?
158. Penicillin?
159. Other antibiotics?
160. Sulfa drugs?
161. Sodium pentothal / Valium /other tranquilizers?
162. Aspirin?
163. Amoxicillin?
164. Codeine or other narcotics?
165. Latex?
166. Soy?
167. Eggs / yolk?
168. Sulfites?
169. Do you have any known allergies?

170. Please list any allergies other than drug allergies:
171. Please list any other medication or antibiotic you are allergic to:**Maximum of 10 allergies for medications/antibiotics**
     1. Medication/Antibiotic #1
     2. Medication/Antibiotic #2
     3. Medication/Antibiotic #3
     4. Medication/Antibiotic #4
     5. Medication/Antibiotic #5
     6. Medication/Antibiotic #6
     7. Medication/Antibiotic #7
     8. Medication/Antibiotic #8
     9. Medication/Antibiotic #9
     10. Medication/Antibiotic #10

172. Family History of Cancer
173. Family History of Diabetes

174. Family History of Heart Disease
175. Family History of Anesthetic Problems

176. Is visit related to an accident?
177. Type of accident- auto/work/other
178. Date of injury

179. Insurance Company Handling Claim
180. Claim Number
181. Attorney or Adjustor
182. Attorney Phone

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

185. Is there any condition concerning your health that the Doctor should be told about
186. If Yes, why?
187. Do you wish to speak to the Dr. privately about anything?