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Form Details

• Form Properties
  1. Form Title: BH020 Wellness Screening Form
  2. Start from an Existing Form - Yes, if there is a previous version signed and locked
  3. Copyrighted Form - No
  4. Billable Progress Note - No
  5. Have multiple versions open at same time - No
  6. Open Blank on new version - No
• Required Fields - Yes
• Lookup Tables - None
• Pre-Fill Logic - Yes
  1. Organization Name will prefill from Setup > Program/Billing Defaults > Company Info
  2. Program Name will prefill from the Program the patient is enrolled in
  3. Medications and Allergies will prefill from ePrescribing
• Fill to Logic - None
• Signatures
  1. Completed By signature
     • Sig type: Any
     • Signature locks the form
     • Route-To is available

Medical Screening Tab

1. Enter the Program Name
2. Enter Doctor’s Name & Address
3. Note Date of Last Exam

Screening Tab (1 of 2)

1. Enter screening information

Screening Tab (2 of 2)

1. Continue to enter screening information

Medications Tab

1. Enter Medication information
   • Any Active Medications will prefill from ePrescribing
     • Select Refresh to refresh
   • Select Surescripts to take to ePrescribe

Allergies Tab

1. Allergies/Drug Sensitivities
   • Grey out - Selecting None will grey out Allergy section
   • Grey out - Selecting ‘Patient has No Known Drug Allergies will grey out the allergy grid
   • Allergies will prefill from ePrescribe
     • Select refresh to update
2. Medical Hospitalizations - Enter hospitalizations
   • Grey out- Selecting No will grey out grid

Nutrition Tab

1. Nutrition/Hydration Screening
   • Grey out - Section defaults to greyed out. Selecting 1 of 3 responses will open text field
2. Pain Screening
   • Grey out - Selecting No will grey out the section

Tobacco Tab

1. Tobacco
   • Entering Yes to “Do you use tobacco products” will make “Are you interested in quitting smoking” required

Personal Routines Tab

1. Enter information regarding Individual’s Personal Routines

Physical Exam Tab

1. For Women Only
   • Grey out - (If male) Section will grey out by default if patient is identified as male in Patient Details
   • Grey out - (If female) Selections greyed out by default
     • Selecting Yes will open the expected due date field
     • Selecting Yes will to pre-natal care will open the Provider field
     • Selecting Yes will open the significant history field
     • Selecting Other to Menstrual Irregularities will open the Other text field
     • Selecting Yes to Polycystic Ovary Syndrome will open Provider field
2. Physical Exam Information
   • When selecting No Physical Exam within past 12 months
     • Select either Be referred for a physical exam (will grey out if no referral text field) or enter info if no referral

Referrals Tab

1. Referrals and Recommendations
   • Grey out - Section defaults to greyed out
     • Selecting a specialty area will open the text field
2. Signature Credentials (see Credentials)
   • Completed By signature
     • Sig type: Any
     • Signature locks the form
     • Route-To is available

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