Microsoft word - dexaquestionnaire_1_.doc

Is there any chance you
6 may be pregnant?

Today’s Date: ________________
Date of Birth:_______________ __
Last Name: ____________________________First Name: _____________________________
Address: ____________________________________________ __________________________ City: ________________________State: ____________Zip Code: _______________________ Referring Doctor’s Name/Address:________________________________________________

__________
Male Female
_____lbs.=________kgs.
This will be done by the bone density technician. ______inches=________cm.
In you adult life, did you ever break a bone either individual, would not have resulted in a fracture? Parent fractured hip Did your mother or father ever break their hip? If you ever did, how many years (approx.)? Were you exposed to oral steroids (prednisone or Medrol etc.) for more than 3 months at a dose of Rheumatoid arthritis Did you doctor ever confirm you were diagnosed with rheumatoid arthritis (not rheumatism or osteoarthritis)? Untreated long-standing hyperthyroidism? Hypogonadism or premature menopause (<45 years)? Do you drink more then 3 or more units of alcohol Have you had a bone density study before? _________When? __________________________________ Where?____________________________________________________________________________ _____ Have you had previous back or hip surgery? _____________________________________________ ___ ___ Family history of osteoporosis or parent/sibling having a hip or spinal fracture?___________ __ _________
Who fractured and what was fractured? ____________________________________________________ Have you had a previous fracture as an adult? (circle) spine______hip_______ wrist______ rib_______ other_____________ How did it happen? __________________________________________________ What was your maximum HEIGHT at age 25 – 35? __________________________________________
Are you (circle): Caucasian, Asian, Hispanic, African American, Other? Other Risk Factors:
Do you stay indoors most of the time/have limited sun exposure?______Yes No a. If yes, what type and how often? _____________________________________________ How many dairy servings do you consume daily? (1 serving = 8oz Milk, Yogurt etc.):_________________ Do you take calcium supplements? Yes No If yes, Brand Name: ________________ mg: _________ How often?____________________________For how long have you been taking this? _______________ Does your supplement/vitamin have vitamin D? _______ How many IU total per day?__________________ Do you have a history of: Parathyroid disease? _______ Seizures____________Anorexi/Bulemia________
Cancer_____If breast, are you taking (circle): Arimidex, Aromasin, Femara, Tamoxifen Years:__________ 12. Medications: (circle/years taken) Anticonvulsants _____Coumadin________ Estrogen_____________
Osteoporosis medication (circle and years taken): Fosamax ____________Actonel_________________
Boniva_________Evista________Forteo____________Reclast________Miacalcin nasal spray________
Do you have frequent falls or unsteadiness?____________________________________________________
FOR WOMEN ONLY:
17. What was your age at menopause (when your menstrual cycle ENDED)_________________or N/A
18. Have your ovaries been surgically removed? ________ If so, at what age? ___________________________ 19. When you were premenopausal (before your menstrual cycles stopped), did you ever have a time for more then 3 months that you had no menstrual bleeding (when not pregnant) Yes No FOR MEN ONLY:
History of impotence? ________________________21. History of infertility? ____________________ 22. Prostate cancer with Lupron injections____ Yes No
Thank you for your cooperation. Your answers will assist your physician in assessing your risk of
developing osteoporosis and in determining which treatment may best fit your needs.
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Source: http://www.njarthritis.com/DEXA_Questionnaire.pdf