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Bone density laboratory

Bone Density Laboratory

Name_______________________ Birth Date____/____/____ Physician___________
Tallest Ht. _____ Present Ht. ______ Present Wt_______ Ethnic Group_______
IS THERE ANY CHANCE YOU MAY BE PREGNANT? YES / NO (CIRCLE ONE)
HAVE YOU HAD A BARIUM X-RAY OR NUCLEAR MEDICINE TEST WITHIN THE LAST 2 WEEKS?
YES / NO (CIRCLE ONE)
By taking the time to completely fill out this questionnaire you are assisting us to properly code your test for
insurance purposes. Without this information your insurance company may refuse payment for this test. Thank
you for your assistance.
Why did your Doctor want you to have this Bone Density Test?

Chronic conditions/illnesses: Please check if applicable
I have been diagnosed with:
_____ Osteoporosis, If true when ________ ______ Organ Transplant
_____ Hyperactive Thyroidism (overactive)
_____ Hyperparathyroidism (overactive)
_____ Hashimoto’s Disease ______ Osteomalacia _____ Cushing’s Syndrome ______ Vitamin D Deficiency _____ Addison’s Disease
Please circle True (T) or False (F) for each of the items on the following pages. If the item does not apply to
you, circle false. If you are uncertain about the question or its meaning, leave it blank and discuss it with us at
the time of your test.
T/F I have gone through menopause. If true, at what age? ______________
T/F My periods are somewhat irregular and I may be in perimenopause
T/F My doctor thinks I may need estrogen supplements
T/F I have had breast cancer
T/F I have a family history of breast cancer
T/F I had a hysterectomy (surgical removal of the uterus only).If true, at what age? ___
T/F I had one / both of my ovaries surgically removed. (Circle one) At what age? ____
T/F I went through menopause before age 45
T/F Previous to menopause, my periods were often irregular
PLEASE TURN THE PAPER OVER AND FILL IN THE BACK SIDE TOO


What Medications have you taken:
T/F I have taken STEROIDS (PREDNISONE).If true, when and for how long? ________
T/F I have taken THYROID PILLS, since _________________
T/F I have taken DILANTIN OR PHENOBARBITAL, since ____________________
T/F I have taken HEPARIN, since _________________ T/F I have taken FOSAMAX, since __________________ T/F I have taken BONIVA, since _______________________________ T/F I have taken MIACALCIN or CALIMAR, since _____________________ T/F I have taken EVISTA, since _______________________ T/F I have taken ESTROGEN (Premarin, Estrogen Patch, etc.), since_____________ T/F I have taken ACTONEL, since _____________ T/F I have taken FORTEO, since _________________ Habits that Effect Bone
T/E I take calcium supplements at least three or four times per week TIF I am unable to tolerate milk products T/F I drink more than 3 alcoholic drinks each day I exercise __ times per week (circle one) 0/week 1-2/week 3-4/week 5-6/week 7/week Risk Factors
T/F I have had a broken bone(s) in the last 5 years? If true, which bone(s): __________________________________________________ How did it happen? _________________________________________ T/F I have lost more than 1 inch in height. T/F I had some bone loss diagnosed previously from an X-Ray. T/F I have developed a curved upper back (“Dowager’s hump”). T/F I have fallen more than 1 time this year. T/F I have a close relative with osteoporosis. If true, which relative(s)? ______________ Please list your present medications and dosages, including CALCIUM and VITAMINS: Thank you for taking the time to complete this questionnaire.

Source: http://www.wchcare.com/files/bone-density-laboratory.pdf

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