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MILFORD HOSPITAL Bone Density Questionnaire Please answer the following questions. If you are not sure how to answer a question, leave the space blank and the technologist will assist you with the answer prior to your exam. Name: Date: Date of birth: Race: Height: African American Weight: Asian Caucasian Sex: Female Male Hispanic Native American Other Referring Physician (if any): YES NO Steroid (prednisone, cortisone etc) Thyroid Medication Anticonvulsants (for seizures, epilepsy) YES NO Kidney disease Rheumatoid (or other) arthritis Heparin Chemotherapy Lithium Growth Hormones Do you take a calcium supplement daily? If so, how much? 0-500mg/day 500-1000mg/day >1000mg/day Hyperthyroidism or hyperparathyroidism Biliary cirrhosis or other Chronic liver problems Loop Diuretics (Lasix, Bumex, Edicrin) Epilepsy Insulin-dependent Diabetes mellitus Part of stomach removed Fractured bone(s) Please answer the follow questions to evaluate your osteoporosis risk level. YES NO Do you have a fair complexion? Do you have a small bone frame? Do you have a family history of osteoporosis or other bone disease? Do you have relatives who have suffered a broken hip, shoulder or wrist after the age of 45? Do you have relatives who have lost height, as they grew older? Questions for women only: YES NO Have you gone through menopause? Did your menopause occur before age 45? Have you ever take hormones (not including birth control pills?) If so, how many years? Have you ever been treated for osteoporosis or weak bones? If so, what was the treatment? Have you had a hysterectomy (womb removed) Have you had ovaries removed? How often do you exercise Infrequently (Times/week Not at all ) YES NO Do you smoke? More than a pack a day? Do you consume alcohol? Less than 3oz./day Greater than 3oz/day
