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The Orthopedic Center
Bone Density Patient Questionnaire

Name: _____________________________________
Street: _____________________________________ City: _____________________________________ Referred by:__________________________________ Primary Physician: __________________________ Other Physicians: _________________________________________________________________________ Is there a chance that you are pregnant? Have you had a barium X-ray in the last two weeks? Have you had a nuclear medicine scan or injection of an X-ray dye in the last week?
Medical History

1. Date of Birth:____________________ Age:_________ Caucasian: ________ African American: ________ Hispanic: ________ Native American: ________ Asian: ________ Other: ________ 3. Have you ever had a bone density test? If Yes, when and where? ____________________________________________________ 4. Have you had a recent weight change? Yes ________ No ________ If Yes, tell us about it: ______________________________________________________ If not a simple fall, please describe the 6. How many times have you fallen in the last year? ______________________________________ 7. List medications you are currently taking, including supplements: _________________________ _________________________________________________________________________________ _________________________________________________________________________________ 8. Are you currently taking or have you previously taken steroid pills (Prednisone) or used an inhaler with steroid in it? If Yes, for how long? _______ What dose? _______mg or _______pills each day 9. Check any of the following that apply to you: Family history of osteoporosis – Who? _____________________________________ Has your Mother or Father had a hip fracture? Yes ________ No ________ Gotten shorter with age? Yes ________ No ________ Have a hump on their back? Yes________ No ________ Back pain – Where? ___________________________________________________ Surgery on back or either hip or forearm? Cancer- type & date: __________________ 10. Are you currently receiving or have you previously received any of the following medications? How Long?
Name of Drug
11. Have you ever been treated with any of the following medications? Medication
If current, how long?
dose (Estrogen/Progesterone) Evista (Raloxifene) Calcimar injection (Calcitonin) Forteo (PTH) 12. Have you ever had Reclast? _______________________________________ 13. How many servings of the following do you eat/drink per day (on average)? Yogurt Cheese Caffeinated Soda Other Calcium fortified 14. Do you take calcium supplements (including TUMS)? If Yes, what brand? ________________________ How many pills per day? ________
15. Do you take any vitamin D supplements? Yes ________ No ________
(including multivitamins and halibut liver oil)
16. Do you, or have you ever, smoked? Yes ________ No ________
If Yes, for how long? ________ Average Packs per Day: ________ Quit Date: ________
17. What do you do for exercise? ______________________________________________
How often? __________________ How long? ________________________________
18. Do you drink alcohol?
No ______ Daily ______ 1-2 x/week ______ 1-2 x/month ______ 1-2 x/year______
For Women Only:
Menstrual History: Are you still having menstrual periods? Yes ________ No ________ If yes, when was your last menstrual period? ____________________ If no, and before menopause, had you ever missed periods for 6 months or more, other If yes, reason _____________________________________________________________ Ever used Norplant or Depo-Provera? Yes ________ No ________ If Yes, when and how long? ___________________________________________ For Men Only: Have you had your testosterone level checked? Yes ________No _______

Technologist Will Complete the Following Section:
Mature Adult Height: _______ Present Height: _______ Historical Loss: ________
Weight: ________ Left/Right Handed: ______________
Has Vitamin D level been checked? _____________________________________________

Source: http://www.theorthopediccenter.net/uploads/docs/Bone%20Density%202.pdf


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