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 |