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BONE DENSITY PATIENT QUESTIONNAIRE Is there a chance that you are PREGNANT? Have you had a barium x-ray in the last 2 weeks? Have you had a nuclear medicine scan or injected of an x-ray dye in the last week? Have you been diagnosed with HYPERPARATHYROIDISM or a HIGH BLOOD CALCIUM level? Yes Yes Yes No No No IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE INFORM THE TECHNOLOGIST RIGHT AWAY. Age: Sex Race: Caucasian Black Have you ever had a bone density test? Do you smoke? Your tallest height, (late teens or young adult? Have you ever broken a bone? Bone’s broken and age when occurred Simple fall? If not, please describe circumstances: Male: Other Yes Female: Yes No Yes No Has a parent or sibling had any type of bone broken from a sample bump or fall? How many times have you fallen the last year? Have you ever had surgery of the spine, hips, legs, or arms? If yes, describe what type of surgery you had an which side was affected? Yes No Yes No Are you currently taking or have you previously taken prednisone pills, (cortisone)? Currently using steroids, (prednisone) Previously used steroids, (prednisone) If yes, for how long? What is your dose? Yes Yes Yes No No No Asian Hispanic No List any chronic medical conditions that you have? Are you currently receiving or have you previously received any of the following: Medication for Yes No Seizure or epilepsy Chemotherapy for cancer Prostate cancer Medication to prevent organ transplant rejection Have you been treated with any of the following medications? Medication Yes Hormone replacement (Estrogen) Tamoxifen Raloxifene (Evista) Testosterone No Currently For how long? If current, how long? Alendronate (Fosamax) Risedronate (Actonel) Eidronate (Didronel) Intravenous pamidronate (Aredia) Calcitonin (Miacalcin nasal spray) PTH (Forteo) Zoledronic Acid (Zometa, Reclast) Boniva FOR WOMEN ONLY Are you still having menstrual Have you had your menopause? If yes, at what age? Have you had a hysterectomy? If yes, at what age? Have you had both ovaries removed? If yes, at what age? Yes Yes No No Thank you for taking time in answering these questions that are very important to the physician that will be interpreting your bone density exam.