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Patient Portal
DEXA Patient History Form
"
*
" indicates required fields
Patient Name:
*
First
Menopause Age:
*
First
Sex:
*
Male
Female
Date of Birth:
*
DD dash MM dash YYYY
Ethnicity:
*
1. Have you had a previous hiporvertebral fracture?
*
Yes
No
2. Have you had any fractures during you radultli few hichdidnot result from significant trauma(e.g. auto accident)?
*
Yes
No
3. Did either of your parents ever have a hipfracture?
*
Yes
No
4. Do you smoke?
*
Yes
No
5. Have you ever taken Glucocorticoids?
*
Yes
No
6. Do you have rheumatoidarthritis?
*
Yes
No
7. Do you have secondary osteoporosis?
*
Yes
No
8. Do you drink 3 or more alcoholic drinks per day?
*
Yes
No
9.Are you be in greated for osteoporosis?
*
Yes
No
10. Have you ever taken any of the following medications:
*
Actonel (i.e.risedronate)
Evista (i.e.raloxifene)
Fosamax (i.e.alendronate)
Miacalcin (i.e.calcitonin)
Reclast (i.e.zoledronate)
Vitamin D
Boniva (i.e.ibandronate)
Forteo (i.e. para thyroid hormone)
HRT (i.e. estrogen/hormone therapy)
Protelos (i.e. strontiumranelate)
Prolia (i.e.denosumab)
Calcium
Other-Please
Specify:
11. Do you have any of the following medical conditions:
*
Anorexia or Bulimia
End stage renal disease
Any Seizure Disorders Asthma or Emphysema
Cancer
Inflammatory bowel diseases
Hyper parathyroidism
Hysterectomy
Other-Please
Specify:
Number
12. What was your maximum height(inches)?
*
13. Do you perform weight bearing exercise regularly?
*
14. Do you regularly consume dairy products?
*
15. Do you drink caffeinated beverages?
*
If female:
16. At what age did your period start?
*
17. Are you pre menopausal ?
*
18. How many full-termpregnancies have you had?
*
19. Have you ever missed your period for more than 6 months inarow(no tincluding pregnancy or menopause)
*
