Download BONE DENSITY PATIENT QUESTIONNAIRE

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.