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? __________________________________
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. (1-1-09)
Đề thi tuyển dụng FPT – ENGLISH TEST A - đề số 3 THE CORPORATION FOR FINANCING AND PROMOTING TECHNOLOGY 50 questions Look at the table below and match the opposites. An example is given. 0. Married _____ C _____ A. Female 1. Neat __________ 2. Bright __________ C. Single 3. Important __________ D. Trivial 4. Male __________ E. Untid
PROGRAM SCHEDULE Seventh Annual SC Upstate Research Symposium April 15, 2011 – held at Milliken & Company Registration, Poster Set-up Opening Remarks: Sebastian van Delden Keynote Address: Dr. Nancy Trun, Duquesne University 9:30-11:05 Breakout Sessions 1,2,3,4,5 Education and Pedagogy Breakout Session 1, 9:30-10:15 Session Chair: Monika Shehi, Lander Un