Bone Density Questionnaire

Bone Density Questionnaire
Patient's name*

First NameMiddle (Optional)Last Name
Birth date*

MonthDayYear
Age
Referring MD*
2nd MD to get report
Prior bone density test: where and when?*
Enter NA if not applicable
Gender*

FemaleMale
Select the most appropriate option*

I've had a hysterectomyI've gone through menopause (change of life)BOTH ovaries have been removedNone of the above
Hysterectomy at what age?
Menopause at what age?
Ovaries removed at what age?
First day of your last period?

MonthDayYear
Your tallest height (as a young adult)*
Current height*
Has a parent or sibling been diagnosed with osteoporosis or a hip fracture?*

YesNo
Which relative had osteoporosis or hip fracture?
Have you ever broken a bone as an adult?*

YesNo
Fracture details (which bone, circumstances, at what age?)
Have you ever had surgery of the spine, hips, or wrists?*

YesNo
Type of surgery and which side?
Check all risk factors and medical conditions that apply*

Currently smoke or have smoked most of my life5 or more cups of caffeinated coffee/ tea/ pop daily3 or more alcoholic beverages dailyHigh blood calcium levels due to a parathyroid issueInsulin-dependent diabetesThyroid disorderCushing's diseaseCrohn's diseaseCeliac disease (sprue)Rheumatoid arthritisNone of the above
Have you taken prednisone pills/ steroids?*

NeverPreviouslyCurrently
How long have you taken prednisone/ steroids?
Have you taken any of the following medications?*

Medication for osteoporosisHormone replacement/ estrogenTamoxifen (Nolvadex) or raloxifene (Evista)Medication for heartburn or ulcerMedication for seizures or epilepsyChemotherapy for cancerMedication for prostate cancerNone of the above
Medication name, for how long?
How much calcium supplements (including Tums) do you take daily?*
How much vitamin D do you take daily?*
How much regular exercise do you do?*
Do you have a known latex allergy?*

* YES *No
Today

MonthDayYear
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