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July 2011 Issue
June 2010 Issue

BONE DENSITY QUESTIONNAIRE

PATIENT INFORMATION:

NAME: *
Current Height (in):
Weight: (lb) :
Menopause Age:
Appointment Date: / /
BIRTHDATE: / / *
Referring Physician:
Ethnicity:

1.Have you had a previous hip or vertebral fracture? YES NO
2.Have you had any fractures during your adult life which did not result from significant trauma (e.g. auto accident)? YES NO
3.Did either of your parents ever have a hip fracture? YES NO
4.Do you smoke? YES NO
5.Have you ever taken Glucocorticoid? YES NO
(please indicate all that apply)
          Prednisone             5 mg or higher
          Dexamethasone       0.8 or higher
          Hydrocortisone        20 mg or higher
          Triamcinolone          4 mg or higher
          Betamethasone        0.7 mg or higher
          Cortisone                25 mg or higher
6.Do you have physician diagnosed rheumatoid arthritis? YES NO
7.Do you have Type 1 insulin dependent diabetes? YES NO
8.Do you have osteogenesis imperfecta? YES NO
9.Do you suffer from malnutrition ? YES NO
10.Do you have chronic liver disease? YES NO
11.Do you drink 3 or more alcoholic drinks per day? YES NO
12.Are you being treated for osteoporosis? YES NO
13.Are you currently taking any of the following medications: YES NO
(Please indicate all that apply)
          Vitamin D
          Calcium
          Actonel (i.e.) risedronate)
          Boniva (i.e. ibandronate)
          Evista (i.e. raloxifene))
          Fosamax (i.e. alendronate)
          Miacalcin (i.e. calcitonin)
          Reclast (i.e. zoledronat))
          HRT (i.e. estrogen/hormone replacement)
          Forteo (i.e. Parathyroid hormone)
          Protelos (i.e. strontium ranelate)
          Prolia (i.e. denosumab)
          Other:  please specify
14.Have you taken any of the following medications in the past? YES NO
(Please note how long you took the mediation and when)

  How long? When?
Vitamin D
Calcium
Actonel (i.e.) risedronate)
Boniva (i.e. ibandronate)
Evista (i.e. raloxifene)
Fosamax (i.e. alendronate)
Miacalcin (i.e. calcitonin)
Reclast (i.e. zoledronate)
HRT (i.e. estrogen/hormone replacement)
Forteo (i.e. Parathyroid hormone)
Protelos (i.e. strontium ranelate)
Prolia (i.e. denosumab)
Other:  please specify 

15.Do you have any of the following medical conditions? YES NO
          Anorexia or Bulimia
          Asthma or Emphysema
          End stage renal disease
          Hyperparathyoidism
          Any seizure disorders
          Cancer
          inflammatory bowel diseases
          Hysterectomy
          Other:  please specify 
16.What was your maximum height? (inches)
17.Do you perform weight bearing exercise regularly? YES NO
# of times per week
18.Do you regularly consume dairy products? YES NO
19.Do you drink caffeinated beverages? YES NO
20.At what age did your period start?
21.Are you premenopausal? YES NO
22.How many full term pregnancies have you had?
23.Have you ever missed your period for more than 6 months in a row? (not including pregnancy or menopause) YES NO

 

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