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Bone questionnaire

BONE DENSITY PATIENT MEDICAL HISTORY
Name: _____________________________ Height: _______ Weight: ______ lbs. Age: _____ yrs. Race:  White  Black  Hispanic  Asian  Other ________________________________ Right or Left Handed  Right  Left Have you had a DEXA Bone Mineral Density exam before?  Yes  No If yes, when and where: __________________________________________________________ Is this exam for  Osteoporosis Screening OR  Monitoring Osteoporosis Treatment
Other reason for exam today? __________________________________________________ MENOPAUSE (Questions for female patients only)
Are you postmenopausal (Have you stopped having a period?) Did you have both of your ovaries removed? Is there a chance you could be pregnant? OSTEOPOROSIS RISK FACTORS
Do you drink three or more alcoholic drinks every day? Do you have a family history of Osteoporosis? Has either of your parents fractured their hip without major trauma? Do you take steroids regularly (>5 mg of prednisone per day for at least 3 months) Do you have a history of fracture; hip, spine, shoulder or forearm without trauma Do you have a history of any of the following? (Check all that apply) Crohn’s, Ulcerative colitis  Chronic antiseizure medication Have you been diagnosed with Rheumatoid Arthritis? Have you lost two inches or more in height since high school? OSTEOPOROSIS
Are you being medically treated for Osteoporosis or Osteopenia (other than Calcium)? If YES, which medication(s) are you taking and for how long?  Fosamax, Fosamax plus D, Dinosto _________  Miacalcin, Fortical, Calcitonin _________  Estrogen or Hormone Replacement Therapy (list) ________________________  Other ____________________________________________________________ BONE DENSITY PATIENT MEDICAL HISTORY
OTHER INFORMATION
Have you had prior surgery to your: (check all that apply)  Lumbar Spine  Right Wrist  Left Wrist
Additional Notes:
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I have read and completed the above questions on the Bone Density Medical History form. I have
been provided the opportunity to ask any questions I may have. I verify this by signing below.

__________________________________________ _________________________________________ If not patient, relationship to patient FOR TECHNOLOGIST USE ONLY
By signing below, I acknowledge the following: 1. I have reviewed the above information on Bone Density Medical History with the patient in its entirety. 2. I provided the patient an opportunity to ask any questions he/she may have. Reviewed by: __________________________________________ Signature: _____________________________________________

Source: http://www.hcavaopimaging.com/wp-content/uploads/2014/01/Bone-Density-History-Sheet-Chesterfield-Imaging.pdf

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