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Bone density questionnaire

Date: _____/_____/______
Please answer the following questions. If you are unsure how to answer a question, please leave the space blank and a staff member
will assist you. Answers are confidential medical record information and are important to assist in the correct interpretation of your
bone density examination.
Name: ______________________________________________ Date of Birth: _____/_____/______
Referring Physician: ________________________________ Sex:
Female______ Male_______

Race: (Please circle one that applies) African-American – Asian – Caucasian (White) – Hispanic – Other

___Yes ___No… Is there a chance that you are pregnant?
___Yes ___No… Have you had a barium X-ray in the last 2 weeks?
___Yes ___No… Have you had a nuclear medicine scan or injection of an X-ray dye in the last week?
___Yes ___No… Did you take any calcium supplements today?
(If you answered yes to any of the above, speak to the Technologist.) GYNECOLOGICAL HISTORY
___Yes ___No… Are you postmenopausal?
___Yes ___No… Did your menopause occur before the age of 45?
___Yes ___No… Have you had a hysterectomy? If so, when? ___________________
___Yes ___No… Have you had your ovaries removed? If so, when? ______________
___Yes ___No… Do you take hormone therapy in any form at this time? If, so, what type? (Circle one that applies)
Premarin – Estrogen – Birth Control
___Yes ___No… Are you currently taking any type of contraception by shot (such as Depo-Provera) that is
intended to stop your periods?


___Yes ___No… Have you ever had a Bone Density (DEXA) Scan before?
If so, when? ________________________ Where? ______________________________ ___Yes ___No… Have you taken Cortisone or Prednisone orally for over 3 months? (Circle all that apply)
___Yes ___No… Do you take thyroid medicine? If so, which do you have (Circle one that applies)
Hypothyroidism – Hyperthyroidism
___Yes ___No. Do you take calcium (including TUMS), multivitamins and/or Vitamin D? (Circle all that apply) If so, how long?_________________________ How much (Dosage)?________________ ___Yes ___No… Do you take any of the following medicine for osteoporosis? (Circle one that applies) Actonel – Boniva – Evista – Fosomax – Miacalcin Nasal Spray
If so, how long? ________________________ How much (Dosage)? _______________ ___Yes ___No… Do you have family history of osteoporosis? ___Yes ___No… Has either parent had a hip fracture? ___Yes ___No… Have you had a confirmed diagnosis of Rheumatoid Arthritis? ___Yes ___No… Have you ever fractured any bones after the age of 40 (excluding hands, feet, and skull)? If so, which Bones? ________________________ How? __________________________

___Yes ___No… Do you currently smoke?
___Yes ___No… Do you drink 3 or more alcoholic beverages daily?
___Yes ___No… Do you exercise regularly? (Walking, Running, Weight Lifting, or Weight Bearing)


Verslag sihon kwaliteitscontrole juni 1999

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