BONE DENSITY QUESTIONNAIRE
DATE: _____________
1. Name: ________________________________________ DOB: _____________________
2. Referring Physician: _______________________________________________________
3. Height: __________________ Weight: _____________ Gender: ___________________
4. Ethnicity:  African American  Asian  Caucasian  Native American
 Hispanic
 Other ____________________________________________
5. Are you currently pregnant or have any reason to believe you may be?  Yes  No
6. MEDICAL HISTORY (Place an "X" by all that apply to you)
 Anorexia, Bulimia, ect.
 Have lost Height, # of inches: __________
 Back Pain
 Hysterectomy, Age: __________________
 Thyroid Disease
 Cancer: Breast/Uterine/Other
 Celiac Disease
 Ovaries Removed
Rheumatoid Arthritis
 Padget's Bone Disease
 Parathyroid Disease
 Date of Last Menstrual Period: _________
 Recurrent Falls
 Menopause, Age: ____________________
 Fractures: Spine / Wrist / Hip / Ankle
 Osteoporosis/Osteopenia
Was the Fracture Trauma related:  Yes  No
Have you ever had a Bone Density Scan ?  Yes  No
If YES When?____________ Where? _______________________________________________
7. FAMILY HISTORY (Place an "X" by all that apply)
 Family History of Osteoporosis  Family History of Hip Fracture - Mother or Father
8. MEDICATIONS (Place an "X" by all that apply)
 Calcium: NONE 500 600 1000 1200
 Once Daily  2/Day
 3/Day
 Contracetion:  Pill
 Shot  Patch  Ring
 Hormone Replacement Therapy:  Compound Hormones  Herbal
 Other
 Actonel
 Alendronate  Atelvia
 Boniva
 Duavee
 Evista
€
 Femara
 Foreto
 Multi-Vitamin
 Miaclcin
 Prolia
Reclast
 Arimidex  Inhaled Steroids
 Oral Steroids: Dosage ________
 Tamoxifen
 Diurectics
 Thyroid  Estrogen
Other Medications Prescribed by a Physician: _______________________________________________
_______________________________________________________________________________________
Medications/herbs/vitamins not prescribed by a Physician: ___________________________________
_______________________________________________________________________________________
9. LIFESTYLE FACTORS (Place an "X" by all the apply)
 Smoking
 Past
Current
 Current
How many alocoholic beverages do you drink per day?
How many Caffienated Beverages do you drink per day?
_____________________________
How many servings of Calcium Rich Food do you eat per day?
_____________________________
How many hours of weight bearing exercise do you per day?
_____________________________