truForm & Eaglesoft Integration Fields

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Instructions below ONLY apply to truForm with Eaglesoft.

This includes ALL fields that integrate from truForm into your Eaglesoft software.  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 any of our standard forms below, the fields listed below are already set to integrate!

• EAGLESOFT STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• GD STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• OMS STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY

We do have fields from our standard forms that will NOT integrate.  Click here to review.

Integrated Field Count:  154 total fields integrate!

1. Patient Information
2. Responsible Party
3. School and Insurance Information
4. Health History
5. Women Only
6. Medications
7. Allergies

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.  [See Example]	*IF YOU ARE USING A CUSTOM FORM: Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.  [See Example]
Prefix First Name Middle Initial Last Name Nickname Gender Martial Description Date of Birth Home Phone Work Phone Work Ext. Cell Phone Email	Address Street Name Apt  City State or Province Zip or Postal Code Driver’s License I would like to receive correspondences via e-mail
*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]
Emergency Full Name Emergency Phone Home

RESPONSIBLE PARTY INFORMATION
*This section will NOT integrate for existing patients already in the system.  This will ONLY integrate for brand new patients that don't have an existing Eaglesoft record.
*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.  [See Example]	*IF YOU ARE USING A CUSTOM FORM: Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.  [See Example]
First Name Middle Initial Last Name Date of Birth Home Phone Work Phone Work Ext Cell Phone	Address Street Name Address Street Name 2 City State or Province Zip or Postal Code Email Address Driver's License

SCHOOL AND INSURANCE INFORMATION
*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.  [See Example] School Name Patient School Address Street Name School City School State or Province School Zip or Postal Code	School Status (Full, Part, Not) Employer Status(Full, Part, Not) Employer ID Medicaid ID

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:
AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disorder Blood transfusion Breathing Problems Bruise easily Cancer Chemotherapy Chest pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting spells Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay fever Heart attack(s) Heart murmur Cardiac pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High blood pressure High cholesterol Hives or Rash Hypoglycemia Irregular heart beat Kidney trouble	Leukemia Liver disease Low blood pressure Lung Disease Mitral valve prolapse Osteoporosis / osteopenia Pain in Jaw Joints Parathyroid Disease Psychiatric care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid trouble Tonsillitis Tuberculosis Tumor or growth Stomach ulcers / acid reflux Sexually transmitted diseases Yellow Jaundice Do you take, or have you take, Phen-Fen or Redux? (cont) If yes explain Do you use controlled substances? (cont) If yes explain Have you ever had a serious head or neck injury? (cont) If yes explain Are you on a special diet? Are you under the care of a physician (cont) If yes explain Have you ever had any serious illness not listed above? (cont) If yes explain Have you had a heart valve replacement or vascular graft? Have you ever been hospitalized or had a major operation? (cont) If yes explain Do you use tobacco?

WOMEN ONLY QUESTIONS
Are you nursing Are you taking birth control pills	Is there a possibility of pregnancy

MEDICATIONS
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 (cont) If yes, explain.	Medication Name (up to 20 medications): Medication #1 Medication #2 Medication #3 Medication #4 Medication #5 Medication #6 Medication #7 Medication #8 Medication #9 Medication #10 Medication #11 Medication #12 Medication #13 Medication #14 Medication #15 Medication #16 Medication #17 Medication #18 Medication #19 Medication #20

ALLERGIES
Acrylic Aspirin Codeine or other narcotics Latex Local anesthetic (numbing meds.) Metal Penicillin Sulfa drugs Please list any allergies other than drug allergies (up to 10 allergies): Allergy #1 Allergy #2 Allergy #3 Allergy #4 Allergy #5 Allergy #6 Allergy #7 Allergy #8 Allergy #9 Allergy #10	Please list any other medication or antibiotic you are allergic to (up to 10 medication/antibiotics): Medication/Antibiotic #1 Medication/Antibiotic #2 Medication/Antibiotic #3 Medication/Antibiotic #4 Medication/Antibiotic #5 Medication/Antibiotic #6 Medication/Antibiotic #7 Medication/Antibiotic #8 Medication/Antibiotic #9 Medication/Antibiotic #10

Eaglesoft does not allow the following fields or sections to be integrated and/or updated, please review below.

1. Social Security Number
   • It is a masked/encrypted field in the software, and must be manually entered by the practice.
2. Policy Holder
   • Services contain extensive logic to validate if claims are open prior to switching. This is not possible with direct database access and can result in a corrupted database.
3. Employer
   • Services contain extensive logic to validate if claims are open prior to switching. This is not possible with direct database access and can result in a corrupted database.
4. Insurance information
   • Services contain extensive logic to validate if claims are open prior to switching. This is not possible with direct database access and can result in a corrupted database.
5. Switching Employer and Insurance information on an existing patient
   • Services contain extensive logic to validate if claims are open prior to switching. This is not possible with direct database access and can result in a corrupted database.
6. Switching Responsible Party on an existing patient
   • Services contain extensive logic to transfer account balances appropriately. This is not possible with direct database access and can result in a corrupted database. 
   • Creation of a Responsible party is allowed on initial patient entry only.

Integration Fields that will NOT Integrate

This list below will include all fields from our standard forms that currently cannot integrate within Eaglesoft.

• EAGLESOFT STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• GD STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY
• OMS STANDARD PBHS PATIENT REGISTRATION & HEALTH HISTORY

*Note, although these fields will not integrate- you will have the completed form (with the question answered) as an attachment within your patients record to review at anytime!

PATIENT INFORMATION Patient Age Social Security Number Payment Method Have you ever been a patient of our practice? Patient Employer Name Preferred Pharmacy Phone Preferred Pharmacy Doctor First Name Doctor Last Name Referred By First Name Referred By Last Name Dentist First Name Dentist Last Name Nearest Relative First Name Nearest Relative Last Name Has a family member ever been a patient of our practice? RESPONSIBLE PARTY INFORMATION Relationship to Patient Relationship to Patient (Other Description) Age Social Security Number Responsible Party Employer Name DENTAL INFORMATION Reason for today’s visit Are you in pain? For how long? Discomfort, clicking, or popping in jaw Red, swollen, or bleeding gums A removable dental appliance Blisters / sores in or around the mouth Prolonged bleeding from an injury / extraction Recent infections or sore throat My teeth are sensitive to hot My teeth are sensitive to cold My teeth are sensitive to sweets My teeth are sensitive to biting Stained teeth Locking jaw Bad breath Toothache Burning tongue / lips Lost / broken filling(s) Teeth grinding / clenching Ringing in ears Broken / chipped tooth Gum disease Difficulty closing jaw Difficulty opening jaw Loose / shifting teeth Food caught between teeth Swelling / lumps in mouth Other Problem Other Description Last dental exam

HEALTH HISTORY INFORMATION Height Weight A history of alcohol abuse A removable dental appliance Are you in good health Chronic fatigue / night sweats Contact lenses Contagious diseases Delay in healing Do you smoke? If so, number of packs a day Gallbladder trouble Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Have you had any illness, operation or been hospitalized in the past five years? Have you ever had general anesthesia? Have you, or a family member, had any unusual or serious reactions to general anesthesia? Heart surgery Infectious mononucleosis Low blood sugar Osteonecrosis Problems with immune system (possibly from med. / surg.) Reason for today’s visit Sleep apnea / CPAP Snoring Trouble climbing 1-2 flights of stairs Swollen Ankles Prosthetic implant SPOUSE OR OTHER GUARANTOR INFORMATION **this entire section does not integrate PRIMARY & SECONDARY DENTAL/MEDICAL INSURANCE **this entire section does not integrate  MEDICATIONS Medication Dosage per each medication Medication Frequency per each medication Antidepressants Blood thinners (Coumadin, Aspirin) Diet pills Insulin Muscle relaxers Nerve pills Pain killers (including aspirin) Stimulants Tranquilizers ALLERGIES Amoxicillin Eggs / yolk Medication / Antibiotic Allergy Sodium pentothal / Valium /other tranquilizers Soy Sulfites Other antibiotics Do you have any known allergies WOMEN ONLY QUESTIONS Expected delivery date EMERGENCY CONTACT INFORMATION Emergency Contact Relation Emergency Contact Work Phone