Please complete the following questions to the best of your ability. If you are unclear what to answer, leave the space blank and we will help with the answer when you are seen at this facility. All answers will be kept in strict confidence and treated as information in your medical record.
1. Your Name:_____________________________________ 2. SS#:_________________________
3. Sex:Female Male   4. Race:Afro-American Asian White Other:_______________
5. Age:___________________   DOB:___/___/___   
6. Referring Physician:______________________________________________________________
7. Have you had fractures or surgery of the spine or hips? _________________________________
8. Any history of cancer? If yes, what type? _____________________________________________
9. What is the main reason your doctor decided you needed this test? ________________________
________________________________________________________________________________
10. Have you had this kind of test done before?Yes No
If yes, where?________________________________________ When?_______________________
11. The following medicines and supplements may be used to treat osteoporosis. Please place a check beside each one you are taking:
alendronate (Fosamax) estrogen (Premarin, Ogen, Estraderm patch, etc.)
calcitonin (Calcimar, Miacalcin) etidronate (Didronel)
calcitriol (Rocaltrol) fluoride
 CALCIUM SUPPLEMENTS parathormone (Parathar)
taking calcium but dose unknown thiazide diuretic (Maxzide, Dyazide, hydrochlorothiazide, etc.)
500-999 mg calcium/day Vitamin D
1000-1499 mg calcium/day 
1500 mg or more calcium/day 
12. Do you have a fair complexion?Yes No
13. Are you slender?Yes No
14. Have any of your relatives suffered a broken hip or shoulder or lost height when past the age of 45?Yes No
15. Do you exercise fewer than three times per week?Yes No
16. Do you drink more than two alcoholic drinks per day?Yes No
17. Have you smoked in the past?Yes No
18. Do you smoke more than 1/2 pack of cigarettes per day?Yes No
19. Do you drink five or more cups of coffee or pop (containing caffeine) each day?Yes No
20. Do you have a low intake of calcium? (Your calcium intake isn't low if you either take calcium supplement most days or if you eat three or more servings of dairy products each day).Yes No
21. Are you now on a form of cortisone (such as prednisone) or have you taken it for more than two months in the past?Yes No
22. Do you take thyroid medication?Yes No
If yes, what?_______________________________________________________ 
23. Do you take anti-convulsants (for seizures, epilepsy)?Yes No
24. Do you take furosemide (Lasix), ethacrynic acid (Edecrin), bumetanide (Bumex), or torsemide (Demadex)?Yes No
25. Do you have partial or complete paralysis?Yes No
26. Do you have hyperthyroidism (overactive thyroid?)Yes No
27. Do you have kidney failure (on dialysis or may need it in the future)? Yes No
28. Do you have rheumatoid arthritis?Yes No
29. Has part of your stomach been removed (gastrectomy)?Yes No
30. Do you have a serious disease of the intestines such as Crohn's disease, ulcerative colitis, or sprue?Yes No
31. Do you have hyperparathyroidism (over-active parathyroid glands)?Yes No
32. Females only: Do you have amenorrhea (never started periods or ended at a young age)?Yes No
33. Females only: Have you ever taken estrogen?Yes No
If yes, for how long and when did you stop?________________________________
34. What is your tallest lifetime measured height in stocking feet?_______________
For office use only


Height_______inches    Weight_______pounds