Microsoft word - ca bmdquestionaire 3 2013 final.doc

Carroll Arthritis, P.A.
Bone Density Scan Risk Assessment Questionnaire

Name (print):______________________________Date of birth: _______________ Date: _______
Have you had a barium X-ray or contrast injection in the last 2 weeks? ……………….Yes No
Which doctor ordered your DXA scan?____________________________________________
Would you like another doctor to have a copy of this report? If yes, name_________________
1. Have you ever had a bone density test? Yes No
If YES, when and where? ____________________________________________________
What was the result? Normal Osteopenia Osteoporosis
2. Have you ever had surgery to your hip, spine or wrist?. Yes No
3. Have you ever broken/fractured a bone as an adult (age 20 or over)? ……….Yes No
Which bone?
How did it happen?
At what age?
4. Has either of your parents suffered a hip fracture? ………………………… Yes No
Is there family history of osteoporosis?__________Yes No Who? ________________
5. Did you ever smoke tobacco? …………………………………………………….Yes No
Current…….Yes No Number of years _____ Year you quit? ________ 6. Do you drink (3+ alcoholic) beverages per day?.Yes No
7. Do you drink 3 or more servings of caffeine daily?.Yes No
8. Have you been diagnosed with Rheumatoid Arthritis? ………………………Yes No
9. Have you ever taken steroids (prednisone) for a long period of time? …. Yes No
If yes, what is the dose_________________ How long?_______________

10. Are you currently or previously taken any of the following medications?
Medication
For how long?
Medication for prostate cancer or breast cancer Medication to prevent organ transplant rejection Water pills (HCTZ, Lasix, furosemide, Bumex, etc)
11. Have you had any of the following conditions?
If yes, how long?
DXA hx form 3 2013

Carroll Arthritis, P.A.
12. Have you ever taken or are currently taking any of these medications for your bones?
Medication

13. How many servings of the following do you eat/drink per day (on average)? None

Cow/other milk______Cheeses______Yogurt____Fortified OJ____Almonds____Green leafy____
14. Do you take any of the following? Check the box, name the brand if you know it
Yes No milligrams

15. Have you ever been diagnosed with vitamin D deficiency? ………………….Yes No
Were you treated with a prescription vit D (50,000 IU) .Yes No

16. Do you do any weight bearing exercise like walking? …….Yes No
How many times per week?_________________________How long? ______________
17. Do you do any strengthening exercise: Weights, Tai Chi, Yoga, resistance bands?.Yes No
18. Have you had any falls in the past year?.Yes No
If yes, how many times______ How did you fall?________________________________

For women only
• Is there any chance you could be pregnant?.Yes No • Have you had a hysterectomy? …………………………………. ….Yes No Did you have your ovaries removed?.Yes No Do/did you take estrogen or progesterone………………………….Yes No • Have you gone through menopause? ………………………… …….Yes No o If yes, at what age? ______
________________________________________________________________________________________
Office use only below this line
Name: ________________________________ PT ID___________ LVA ______FRAX________
Weight _______ Changes? ____________________ Reason____________________________
Tallest height ___________ Cal dietary___________ vit D dietary__________ Prior DXA__________
Current height___________ Cal pills_____________ vit D pills____________ dx________________
Change ___________ Total________________ Total ________________
BHE given to patient Y____ N Samples Given Y ______ N Fee Ticket ___Y___N Technical_______
DXA hx form 3 2013

Source: http://www.carrollarthritis.com/images/BMDqtr.pdf