truForm & DSN Integration Fields (v18x and above)

Integration Field Count: 241 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.  [See Example]

1. Prefix
2. First Name
3. Last name
4. Middle Initial
5. Gender
6. Date of Birth
7. Social Security Number
8. Work Phone
9. Home Phone
10. Cell Phone
11. Email
12. Employer Name

13. Address Street Name
14. Apt 
15. City
16. State or Province
17. Zip or Postal Code
18. Employer Name

19. Referred By First Name
20. Referred By Last Name

1. Nickname
2. Suffix
3. Age
4. Drivers License
5. Dentist First Name
6. Dentist Last Name
7. Doctor First Name
8. Doctor Last Name

1. Orthodontist First Name
2. Orthodontist Last Name
3. Nearest Relative First Name
4. Nearest Relative Last Name
5. Nearest Relative Phone Number
6. Preferred Pharmacy
7. Pharmacy Tel
8. Personal Payment Type

1. Have you ever been a patient of our 
   practice?
2. Has a family member ever been a patient of our practice?
3. Emergency Full Name
4. Phone Home
5. Phone Work
6. Emergency Relation to Patient

This entire section will not integrate:

SPOUSE OR OTHER GUARANTOR INFORMATION

RESPONSIBLE PARTY INFORMATION

*IF YOU ARE USING A CUSTOM FORM: Responsible Party Name on the form must be split out into first name last name in order to integrate correctly.  [See Example]

21. Relationship to Patient
22. Prefix (ex. Mr., Mrs., Miss., Dr.)
23. First Name
24. Last Name
25. Middle Initial
26. Suffix
27. Social Security Number
28. Home Phone
29. Work Phone
30. Cell Phone
31. Email 

32. Address Street Name
33. Address Apt #
34. Address City
35. Address State or Province
36. Address Zip or Postal Code 

DOES NOT INTEGRATE:

1. Employer Name
2. Age
3. Date of Birth
4. Drivers License
5. Relationship description (if other)

This entire section will not integrate:

SCHOOL AND INSURANCE INFORMATION

1. School Name
2. School Address Street
3. School Address City
4. School Address State or Province
5. School Address Zip or Postal Code

6. Student Status (full/part/not)
7. Employment status (full/part/retired/not)
8. Marital Status (married/ divorced/ widow/ single/ legally separated)

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.   [See Example]

*IF YOU ARE USING A CUSTOM FORM: All Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.  [See Example]

*IF YOU ARE USING A CUSTOM FORM: Insured Name on the form must be split out into first name last name in order to integrate correctly.  [See Example]

PRIMARY DENTAL

37. Primary/Secondary Insurance Type (Dental, Medical, Both)
38. Insured First Name
39. Insured Middle Initial
40. Insured Last Name
41. Insured Gender
42. Insured Social Security Number
43. Insured Date of Birth
44. Insured Home Phone Number
45. Insured Street Address
46. Insured Home Address Street
47. Insured Home Address City
48. Insured Home Address State or Province
49. Insured Home Address Zip or Postal Code
50. Insurance Company Name
51. Insurance Company Address Street
52. Insurance Company Address City
53. Insurance Company Address State or Province
54. Insurance Company Address Zip or Postal Code
55. Insurance Company Phone Number
56. Insured Insurance Policy Group Number
57. Insured Insurance Policy ID
58. Insured Employer Name
59. Insured Employer Address Street
60. Insured Employer Address City
61. Insured Employer Address State or Province
62. Insured Employer Address Zip or Postal Code
63. Insured Employer Phone Number
64. Insured Relationship

SECONDARY DENTAL

93. Primary/Secondary Insurance Type (Dental, Medical, Both)
94. Insured First Name
95. Insured Middle Initial
96. Insured Last Name
97. Insured Gender
98. Insured Social Security Number
99. Insured Date of Birth
100. Insured Home Phone Number
101. Insured Street Address
102. Insured Home Address Street
103. Insured Home Address City
104. Insured Home Address State or Province
105. Insured Home Address Zip or Postal Code
106. Insurance Company Name
107. Insurance Company Address Street
108. Insurance Company Address City
109. Insurance Company Address State or Province
110. Insurance Company Address Zip or Postal Code
111. Insurance Company Phone Number
112. Insured Insurance Policy Group Number
113. Insured Insurance Policy ID
114. Insured Employer Name
115. Insured Employer Address Street
116. Insured Employer Address City
117. Insured Employer Address State or Province
118. Insured Employer Address Zip or Postal Code
119. Insured Employer Phone Number
120. Insured Relationship

PRIMARY MEDICAL

65. Primary/Secondary Insurance Type (Dental, Medical, Both)
66. Insured First Name
67. Insured Middle Initial
68. Insured Last Name
69. Insured Gender
70. Insured Social Security Number
71. Insured Date of Birth
72. Insured Home Phone Number
73. Insured Street Address
74. Insured Home Address Street
75. Insured Home Address City
76. Insured Home Address State or Province
77. Insured Home Address Zip or Postal Code
78. Insurance Company Name
79. Insurance Company Address Street
80. Insurance Company Address City
81. Insurance Company Address State or Province
82. Insurance Company Address Zip or Postal Code
83. Insurance Company Phone Number
84. Insured Insurance Policy Group Number
85. Insured Insurance Policy ID
86. Insured Employer Name
87. Insured Employer Address Street
88. Insured Employer Address City
89. Insured Employer Address State or Province
90. Insured Employer Address Zip or Postal Code
91. Insured Employer Phone Number
92. Insured Relationship

SECONDARY MEDICAL

121. Primary/Secondary Insurance Type (Dental, Medical, Both)
122. Insured First Name
123. Insured Middle Initial
124. Insured Last Name
125. Insured Gender
126. Insured Social Security Number
127. Insured Date of Birth
128. Insured Home Phone Number
129. Insured Street Address
130. Insured Home Address Street
131. Insured Home Address City
132. Insured Home Address State or Province
133. Insured Home Address Zip or Postal Code
134. Insurance Company Name
135. Insurance Company Address Street
136. Insurance Company Address City
137. Insurance Company Address State or Province
138. Insurance Company Address Zip or Postal Code
139. Insurance Company Phone Number
140. Insured Insurance Policy Group Number
141. Insured Insurance Policy ID
142. Insured Employer Name
143. Insured Employer Address Street
144. Insured Employer Address City
145. Insured Employer Address State or Province
146. Insured Employer Address Zip or Postal Code
147. Insured Employer Phone Number
148. Insured Relationship

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:

149. Are you in good health
150. Height
151. Weight
152. Have there been any changes in your general health in the pas year
153. Are you under the care of a physician
154. Date of last visit
155. If so, for what are you being treated
156. Have you had any illness, operation or been hospitalized in the past five years
157. If so describe
158. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth
159. If so, describe where
160. Do you have a prosthetic joint / implant
161. If so, describe where
162. Have you had a heart valve replacement or vascular graft
163. Have you ever had general anesthesia
164. Have you, or a family member, had any unusual or serious reactions to general anesthesia
165. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment
166. Rheumatic fever
167. Damaged heart valves / mitral valve prolapse
168. Heart murmur
169. High blood pressure
170. Low blood pressure
171. Chest pain / angina
     • Comes over as angina
172. Heart attack(s)
173. Irregular heart beat
174. Cardiac pacemaker
175. Heart surgery
176. Pneumonia, bronchitis, chronic cough
     • Comes over as bronchitis/chronic cough
177. Asthma
     
178. Hay fever / sinus problems
179. Snoring
180. Sleep apnea / CPAP
181. Difficult breathing / other lung trouble
     • Comes over as other lung trouble
182. Tuberculosis
183. Emphysema
184. Do you smoke or vape
     • DOES NOT INTEGRATE:
       If so, how much a day do you smoke/vape
       

185. Do you use chewing tobacco

186. Blood transfusion
187. Blood disorder such as anemia
     • Comes over as anemia
188. Bruise easily
189. Bleeding tendency / abnormal bleed
     • Comes over as bleeding tendency
190. Hepatitis, jaundice, or liver disease
191. Infectious mononucleosis
192. Gallbladder trouble
193. Fainting spells
194. Convulsions / epilepsy
195. Stroke
196. Thyroid trouble
197. Diabetes
198. Low blood sugar
199. Kidney trouble
200. High cholesterol
201. Are you on dialysis
202. Swollen ankles / arthritis / joint disease
     • Comes over as arthritis
203. Osteoporosis / osteopenia
204. Osteonecrosis
205. Stomach ulcers / acid reflux
     • Comes over as stomach ulcers
206. Contagious diseases
207. Sexually transmitted diseases
208. Problems with immune system? Possibly from medication / surgery, etc.
209. Delay in healing
210. A tumor or growth
211. Cancer / radiation therapy / chemotherapy
     • Comes over as xray or chemo
212. Chronic fatigue / night sweats
213. Are you on a diet
214. A history of alcohol abuse
215. A history of marijuana or other drug use
216. Contact lenses
217. Eye disease / glaucoma
218. Mental health problems / anxiety / depression
     • Comes over as mental health problems)
219. A removable dental appliance
220. Pain or clicking of jaws when eating

DOES NOT INTEGRATE:

1. COVID-19
2. Autoimmune disease
3. Alcohol intake? 
4. If so, drinks per Day
5. If so, drinks per Week

 This entire section will not integrate:

WOMEN ONLY

MEDICATION 

221. Any kind of medication, drug, pills
222. Please list any medication you are currently taking:
     (1-20 list, including medication name, dosage and frequency)
     If you are using a CUSTOM FORM!! 
     This question must be accompanied by a YES/NO question in order to integrate into your software correctly. 
     Ex:  Are you taking any kind of medication, drug, pills?  YES / NO

DOES NOT INTEGRATE:

1. Blood thinners (coumadin, plavix, aspirin, vitamin E, Ginko biloba, aggrenox, Xarelto, Eliquis, Fish oil)
2. Have you ever taken diet pills
3. Any natural product, herbal supplement or homeopathic remedy
4. Are you taking, or have you ever taken, bone density meds. RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years
5. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis 
   • If so, please list:
6. If you are under the care of a physician for pain management, or recovering from drug addition please select the medication you are currently taking
   • Treating doctor first name
   • Treating doctor last name

ALLERGIES

223. Local anesthetic (numbing meds.)
224. Penicillin
225. Other antibiotics
226. Sulfa drugs
227. Sodium pentothal / Valium /other tranquilizers
228. Aspirin
229. Amoxicillin
230. Codeine or other narcotics
231. Latex
232. Soy
233. Eggs / yolk
234. Sulfites
235. Do you have any known allergies

236. Please list any allergies other than drug allergies:
     If you are using a CUSTOM FORM!! 
     This question must be accompanied by a YES/NO question in order to integrate into your software correctly. 
     Ex:   Do you have any known allergies?  YES / NO
     
237. Please list any other medication or antibiotic you are allergic to:
     
     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

FAMILY HISTORY

238. Family History of Cancer
239. Family History of Diabetes

240. Family History of Heart Disease
241. Family History of Anesthetic Problems

This entire section will not integrate:

INJURY INFORMATION

1. Date of injury
2. Type of accident- auto/work/other
3. Insurance Company Handling Claim
4. Claim Number
5. Attorney or Adjustor
6. Attorney Phone

This entire section will not integrate:

HEALTH HISTORY PERSONAL INFORMATION

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