Microsoft word - dexa_medical hxquestionnaire2008 (2).doc

Northwest Osteoporosis Center
Medical History Questionnaire
Name: _________________________________ Age: _______________ Date: _______________________
Referred By: ____________________________ Gender: M F Scan No: ________________________
Wt. _________ Ht. __________ Birthdate: __________________
Ethnic Background:
Caucasian
African American
Asian
Hispanic

Why has your referring physician sent you here? _________________________________________________ Have you fractured your hip, back, shoulder or wrist as an adult? If so, please describe how the fracture occurred (eg: fall, accident etc.) and at what age? _________________________________________________________________________ Have either of your parents fractured a hip? Do you have a family history of osteoporosis? Are you currently on a steroid medication (prednisone, cortisone, dexamethasone, solumedrol)? If yes, what dose________________? Have you ever been on 5 mg. per day or higher of prednisone for over 3 months? Do you have a known diagnosis of any of the following: Untreated hyperthyroidism (overactive thyroid) Do you currently consume more than 3 alcoholic beverages a day? Have you had any nuclear or barium testing recently? Please list all current medications and supplements. Include milligrams & length of time taking each. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Davis HD:Users:jsd:Desktop:DEXA_Medical HxQuestionnaire2008 (2).doc Northwest Osteoporosis Center
Have you ever taken any of the following medications? Thyroid
Yes
No Prednisone
Yes
No Miacalcin
Yes
No Fosamax
Yes
No Cortisone
Yes
No Boniva
Yes
No Dilantin
Yes
No Which of the following do you consume on a daily basis?
Milk, 8 oz (350mg) How many glasses per day?
Whole Wheat Bread (25 mg) Slices per day?
Yogurt, 8 oz. Indicate which type:
Fruit
Plain (300 mg) (400 mg)
Cheese, 1 oz (200 mg)
Calcium Fortified Cereal, ( 3/4 C cereal with 1/2 C milk 300 mg).
Calcium Fortified Orange Juice, 8 oz (300 mg)
Ice Cream or Frozen Yogurt, 8 oz. (175 mg)
Calcium Fortified Rice or Soymilk, 8 oz (300 mg)
Broccoli,1/2 C (60 mg); Dried Beans 1/2 C (60 mg); _____________________ Total Dietary Calcium Do you take a calcium supplement? If yes, total milligrams per day: _______________ Does the product contain vitamin D? If yes, amount: ____________________ Are you taking a vitamin D supplement? If yes, amount:___________________ Total Vitamin D ________________ Total Calcium _____________________ Are you post-menopausal? If yes, what age? _________________ Have you had a hysterectomy? If yes, what age? _________________ Have you had your ovaries removed? If yes, what age? __________________ Have you ever taken estrogen replacements? If yes, how long? ____________ Have you ever had prolonged absence of periods other than child-birth or menopause? Do you exercise? If yes, what and how often? ______________________________________
Yes
No Davis HD:Users:jsd:Desktop:DEXA_Medical HxQuestionnaire2008 (2).doc

Source: http://www.nwrheumatology.org/wp-content/uploads/sites/11/2012/12/Dexa-Medical-History-Questionnaire.pdf