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? MEDICAL HISTORY ___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)
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41466 Metavante_FormularyI:GHI_2008_FormularyI 5/23/08 8:00 PM Page 1 The fol owing is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your pharmacy benefit plan. The list is not al - inclusive and does not guarantee coverage. In addition to using the list, you are encouraged to ask your doctor to pres