Note - Standard Forms will have a black paper icon next to the Form name. Writeback forms will be shown in green, as shown below:

| Eaglesoft Medical History | Will Write back? |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes | |
| Yes, if missing. No, if existing. | |
| Eaglesoft Medical History | Will Write back? |
| Patient Name | No |
| Birth Date | Yes |
| Date Created | Yes (Date form was overwritten to Eaglesoft.) NOTE: May not be the same date as what the patient indicated on the form. |
| No To ALL | No |
| Are you under a physician's care now? | Yes |
| If yes (connected to Are you under a physician's care now?) | Yes |
| Have you ever been hospitalized or had a major operation? | Yes |
| If yes (connected to Have you ever been hospitalized or had a major operation?) | Yes |
| Have you ever had a serious head or neck injury? | Yes |
| If yes (connected to Have you ever had a serious head or neck injury?) | Yes |
| Are you taking any medications, pills, or drugs? | Yes |
| If yes (connected to Are you taking any medications, pills, or drugs? ) | Yes |
| Do you take, or have you taken, Phen-Fen or Redux? | Yes |
| If yes (connected to Do you take, or have you taken, Phen-Fen or Redux? ) | Yes |
| Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? | Yes |
| If yes (connected to Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?) | Yes |
| Are you on a special diet? | Yes |
| Do you use tobacco? | Yes |
| Do you use controlled substances? | Yes |
| If yes (connected to Do you use controlled substances?) | Yes |
| | |
| No To ALL | No |
| Women: Are you… | NA |
| | |
| Pregnant/Trying to get pregnant? | Yes |
| Nursing? | Yes |
| Taking oral contraceptives? | Yes |
| | |
| Are you allergic to any of the following? | NA |
| | |
| Aspirin | Yes |
| Penicillin | Yes |
| Codeine | Yes |
| Acrylic | Yes |
| Metal | Yes |
| Latex | Yes |
| Sulfa Drugs | Yes |
| Local Anesthetics | Yes |
| Other | ??? |
| If yes (connected to Other?) | ??? |
| | |
| | |
| No To ALL | |
| AIDS/HIV Positive | Yes |
| Alzheimer's Disease | Yes |
| Anaphylaxis | Yes |
| Anemia | Yes |
| Angina | Yes |
| Arthritis/Gout | Yes |
| Artificial Heart Valve | Yes |
| Artificial Joint | Yes |
| Asthma | Yes |
| Blood Disease | Yes |
| Blood Transfusion | Yes |
| Breathing Problems | Yes |
| Bruise Easily | Yes |
| Cancer | Yes |
| Chemotherapy | Yes |
| Chest Pains | Yes |
| Cold Sores/Fever Blisters | Yes |
| Congenital Heart Disorder | Yes |
| Convulsions | Yes |
| Cortisone Medicine | Yes |
| Diabetes | Yes |
| Drug Addiction | Yes |
| Easily Winded | Yes |
| Emphysema | Yes |
| Epilepsy or Seizures | Yes |
| Excessive Bleeding | Yes |
| Excessive Thirst | Yes |
| Fainting Spells/Dizziness | Yes |
| Frequent Cough | Yes |
| Frequent Diarrhea | Yes |
| Frequent Headaches | Yes |
| Genital Herpes | Yes |
| Glaucoma | Yes |
| Hay Fever | Yes |
| Heart Attack/Failure | Yes |
| Heart Murmur | Yes |
| Heart Pacemaker | Yes |
| Heart Trouble/Disease | Yes |
| Hemophilia | Yes |
| Hepatitis A | Yes |
| Hepatitis B or C | Yes |
| Herpes | Yes |
| High Blood Pressure | Yes |
| High Cholesterol | Yes |
| Hives or Rash | Yes |
| Hypoglycemia | Yes |
| Irregular Heartbeat | Yes |
| Kidney Problems | Yes |
| Leukemia | Yes |
| Liver Disease | Yes |
| Low Blood Pressure | Yes |
| Lung Disease | Yes |
| Mitral Valve Prolapse | Yes |
| Osteoporosis | Yes |
| Pain in Jaw Joints | Yes |
| Parathyroid Disease | Yes |
| Psychiatric Care | Yes |
| Radiation Treatments | Yes |
| Recent Weight Loss | Yes |
| Renal Dialysis | Yes |
| Rheumatic Fever | Yes |
| Rheumatism | Yes |
| Scarlet Fever | Yes |
| Shingles | Yes |
| Sickle Cell Disease | Yes |
| Sinus Trouble | Yes |
| Spina Bifida | Yes |
| Stomach/Intestinal Disease | Yes |
| Stroke | Yes |
| Swelling of Limbs | Yes |
| Thyroid Disease | Yes |
| Tonsilitis | Yes |
| Tuberculosis | Yes |
| Tumors or Growths | Yes |
| Ulcers | Yes |
| Venereal Disease | Yes |
| Yellow Jaundice | Yes |
| | |
| | |
| Have you ever had any serious illness not listed above? | Yes |
| If yes (connected to Have you ever had any serious illness not listed above?) | Yes |
| | |
| Comments | Yes |
| | |
| Signature | No (ES Limitation) |
| Date | Yes |
| | |
| Pre-Med Necessary | Yes -- Edit Patient, Preferences |
