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Microsoft word - form #8 patient osteoprosis.docx

Novi 24285 Karim Blvd. 48375
Phone 248.536.0410
Fax 248.536.0420
Trenton 1676 Fort Street 48183
Phone 734.362.0900
Fax 734.362.0911
Patient Form Ÿ Bone Densitometry Ÿ Osteoporosis
Patient Name: _________________________________________________________________ Today's Date: _____/_____/_______
Date of Birth: _____/_____/_______ Are you or do you think you're pregnant? Yes _____ No _____ Not Sure _____
Have you had a Barium X-Ray in the past two weeks? Yes ☐ No ☐
Have you had a Nuclear Medicine scan, or any contrast agent (X-Ray, or CT Scan) in the past seven days? Yes ☐ No ☐
Have you had hyperparathyroidism, or a high calcium level in your blood? Yes ☐ No ☐
IMPORTANT: If you answered yes to any of the above questions, please speak to our technologist right away.

Age: _______ Sex: Male ☐ Female ☐
Ethnicity - Please check one: Caucasian (white) ☐ African American ☐ Aboriginal ☐ Asian ☐ Hispanic ☐Indian ☐ Other ☐
Have you ever had a Bone Density test? Yes ☐ No ☐ If yes, when and where? __________________________________________
Have you had a recent weight change? Yes ☐ No ☐ If yes, what has happened? _______________________________________
What is your current weight: __________ lbs. You’re weight (late teens, or young adult)? _____________________________
Have you ever broken a bone? Yes ☐ No ☐ If yes, please state on the chart below.

Has a parent or sibling had a hip fracture from a simple fall or bump? Yes ☐ No ☐ Has a parent of a sibling had any other type of broken bone from a simple fall or bump? Yes ☐ No ☐ How many times have you fallen in the past year? _______ Have you ever had surgery of the spine, hip, arms, or legs? Yes ☐ No ☐ If yes, describe what type of surgery you had, and which side was affected? ______________________________________________________________________________________ Are you currently receiving, or have you previously received prednisone pills (cortisone)? No ☐ Yes - Currently ☐ Yes - Previously ☐ If yes, for how long? __________ What is the dosage? __________ mg, or __________ pills each day. Please list any chronic medical conditions that you have: ______________________________________________________________ ____________________________________________________________________________________________________________ Measured Height: __________ Confirmed Weight: __________ Patient Form Ÿ Bone Densitometry Ÿ Osteoporosis Ÿ Page Two Are you currently receiving, or have you previously received any of the following medication? Type of Condition
For How Long?
Medication to prevent organ transplant rejection
Have you been treated with any of the following medications?

If Current, How Long?
Please list any additional bone density therapy if not listed above: ___________________________________________________ ____________________________________________________________________________________________________________ How many servings of the following do you eat, or drink a day (on average) Number of Servings
Do you take any calcium supplements (including Tums)? Yes ☐ No ☐
Did you take any Vitamin D supplements (including multi-vitamins and Halibut Liver Oil)? Yes ☐ No ☐
Do you smoke? Yes ☐ No ☐ If yes, when do you plan on quitting? ________________________________________________
FOR FEMALE PATIENTS: Are you still menstruating? Yes ☐ No ☐

Before menopause, have you ever missed periods for six months or more, other than during a pregnancy? Yes ☐ No ☐

Have you had menopause? Yes ☐ No ☐ If yes, what age? _______ Have you had a hysterectomy? Yes ☐ No ☐ If yes, what age?
Have you had both ovaries removed? Yes ☐ No ☐ If yes, at what age?
Patient Signature: ____________________________________________________________________________________________
For Technologist Use: _________________________________________________________________________________________ ________________________________________________________________ Technologist Initials: __________ Revised 11-7-2012



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Nacwa - a white paper on pharmaceuticals and personal care products in the environment

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