National Osteoporosis Foundation Professional Partner Network Member 2305 Genoa Business Park Drive, Suite 170, Brighton, MI, 48116 (810) 299-8550 Osteoporosis Patient History Form Please answer the following questions to help us in the treatment of your bones. If you are not sure how to answer a question, leave the space blank and we will assist you with your answer. All answers will of course be kept in strict confidence and treated as medical record information. Name:__________________________________________________________________
Referring Physician (if any): ________________________________________________
Important Questions about your Health (Please Circle)
Have you ever had a fracture or broken bone?
Did either of your parents ever fracture their hip?
Do you take glucocorticoids or steroids such as prednisone?
Have you been diagnosed with Rheumatoid arthritis?
Do you drink three or more units of alcohol
(glasses, bottles, shots) on a normal day?Have you had any of the following conditions?
If yes, please check those diagnosed____Hyperthyroidism
____Eating disorders (anorexia nervosa, bulimia, etc.)
Have you ever been treated for Osteoporosis?
(common treatments include: Fosomax, Actonel, Boniva, Miacalcin, Forteo)Did you have to discontinue any of these for any reason?
If so, why? ______________________________________________________________
Do you have GERD, heartburn, or history of ulcers or strictures? YES
Do you have frequent nose bleeds or nasal mucosa problems?
Do you have severe dental problems such as abscess or extractions YES
Questions about your Calcium and Vitamin D Intake: How many servings of dairy products do you have each day? ______________________ (one serving = 8oz. milk, 1.5oz. cheese, 8oz. yogurt, 8oz.cottage cheese, 4oz. ice cream) Have you consumed three or more dairy servings per day throughout most of your life? (continued on next page)
If so, how many milligrams of Calcium are in your supplement? __________________________________________How many supplements do you take per day?________________Do you take Vitamin D supplements daily?
If so, how many international units of Vitamin D are in your supplement? _________________________________________How many supplements do you take per day? _______________Do you take a Multi vitamin Daily?
Do you have any general comments or questions about your health?
ALL questions below ONLY required for those under 40 or over 90 years of age
Is your current body weight under 127 pounds?
NODo you spend less than 20 minutes outside each day?
Is your eyesight impaired such that it interferes with walking?
Do you drink more than 2 cups of coffee or 4 cans (12oz.) of
caffeinated soda per day?Do you frequently fall or have problems with your balance?
Do you exercise less than three times per week?
If you exercise, what type typically? ____Aerobic dance
Does your family have a history of Osteoporosis?
Have you taken any of the following medications or treatments? YES
If yes, please check those you have taken____Steroids (prednisone, cortisone, etc.)
____Anticonvulsants (for seizures, epilepsy)
____Loop Diuretics (Lasix, Bumex, Edicrin)
____Methotrexate (medication for Rheumatoid Arthritis)
____Cholestyramine (Questran to lower cholesterol) Questions for Women only (those under 40 or over 90 years of age) Have you gone through menopause?
At what age did you go through menopause? _______________Have you ever had amenorrhea?
(missed periods or never started periods)Have you ever take hormones? (not including birth control pills)
If so, for how many years? _____________________________Have you ever had your ovaries removed?
National Osteoporosis Foundation Professional Partner Network Member 2305 Genoa Business Park Drive, Suite 170, Brighton, MI, 48116 (810) 299-8550 Preparing for Bone Densitometry Scanning
• Unless instructed otherwise by one of our clinicians, eat normally on
• Avoid taking calcium supplements for at least 24 hours prior to your
• Wear loose, comfortable clothing to the scan. Sweat suits and other
casual attire without zippers, buttons, grommets, or any metal are preferred.
• You should not have had a barium study, radioisotope injection, oral
or intravenous contrast material from a CT or MRI within seven days of your Dexa Scan test.
• You need to wait 6 weeks after a fracture before having a Dexa scan
• You need to be able to lay flat on your back for 20 minutes.
Please plan to schedule your follow-up appointment with our office following your scan. One of our orthopedic physicians will make recommendations for your bone health based upon not only your scan results, but also from your answers to the questions on this form, and your clinical exam. Consequently, we are unable to provide the results of the test over the phone. For this reason, it is important that you attend your follow-up appointment. We would be happy to send these results to your primary care physician. Please inform our technician, and we will send the results, along with a comprehensive letter of our recommendations, after your follow-up visit.
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