Bone Density
Patient Questionnaire

MORELAND OB-GYN BONE DENSITY PATIENT QUESTIONNAIRE NAME: ________________________________  

TODAY'S   DATE: _________________

PRIMARY MD:  __________________________

Do you want a copy to be sent to primary MD?   ____

1. Is there a chance you may be pregnant?   Yes ___  No ___

2.  Have you had a barium x-ray in the last 2 weeks?   Yes ___  No __

3.  Have you had a nuclear medicine scan or injection of an x-ray dye in the last week?  Yes ___  No __

4.  Ethnicity:  Caucasian (white) ___   Black ___   Asian ___  Hispanic ___  Other __

5.  Have you ever had a Bone Density Test?   Yes ___  No ___ If yes, where was it done? __________________________

6. Your tallest height (late teens or young adult) __________

7. Have you ever broken a bone?   Yes ___  No ___ If yes, which bone did you break? ________________   How did you break it? __________________ At what age did you break it? _______ (A previous fracture denotes more accurately a fracture in adult life occurring spontaneously or a fracture arising from trauma, which in a healthy individual, would not have resulted in fracture.)

8. Do you have a family history of osteoporosis?   Yes ___  No ___

9. Has a parent or sibling had a broken hip from a simple fall or bump?   Yes ___  No ___

10. Has a parent or sibling had any other type of broken bone from a simple fall or bump? Yes ___ No __

11. How many times have you fallen during the last year? _____________

12. Are you currently receiving or have you previously received Prednisone of Cortisone?  Yes currently ___  Yes previously ___  For how long? __________  What is/was your dose? _________

13. List any chronic medical conditions that you have: ________________________________________  __________________________________________________________________________________  __________________________________________________________________________________
Are you currently receiving or have you previously received any of the following medications?

 

	No	Yes	For how long?
Medication for seizures or epilepsy
Chemotherapy for cancer
Medication to prevent organ transplant rejection

14. Have you been treated with any of the following medications?

	Ever?	Currently?	If currently, for how long?
Hormone replacement therapy (Estrogen)
Tamoxifen
Evista (Raloxifene)
Armidex
Testosterone
Fosamax (Alendronate)
Actonel (Risedronate)
Boniva (Ibandronate Sodium)
Forteo (PTH)
Reclast (Zoledronic Acid)

 

15. How many days a week do you exercise?____ How long do you exercise each time? ______ What kind of exercise do you do? ____________________________________________________________________________________________  ________________________________________________________________________________

16. How many servings of the following do you eat or drink per day on average?

Serving size	Milk 1 cup	Calcium enriched orange juice 1 cup	Yogurt 1/2 cup	Cheese 1 oz.	Other calcium rich foods 1 cup
Number of servings

 

17. Do you take Calcium supplements (including Tums) Yes ___  No ___  How much?  __________

18. Do you take a Multivitamin? Yes ___  No ___

19.  Do you take a Vitamin D supplement? Yes ___  No ____  How much? __________

20. Do you take Fish Oil? Yes ___  No ___

21. Do you smoke? Yes ___  No ___

22. How much caffeine do you drink each day? _____________________________________________

23.How much alcohol do you drink each day? _____________________________________________

24. Are you still having periods? Yes ___ No ___

25. Have you had your menopause? Yes ___  No ___  If yes, how old were you? _____

26. Have you had a hysterectomy? Yes ___  No ___  If yes, how old were you? _____

27. Have you had both of your ovaries removed? Yes ___  No ___