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The Orthopedic Center
Bone Density Patient Questionnaire
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?
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?
Name of Drug
11. Have you ever been treated with any of the following medications?
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? _____________________________________________
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