Deschutes Osteoporosis Center, LLC
Name
Account #
Birthdate
Street
Height
Referring Physician
City, State, Zip
Weight
Primary Physician
Tallest Height
Today's Date
Phone (
)
Age
Sex
In the past two weeks, have you had any x-ray studies:
Contrast agent/dye?
Date
Have you ever had any of the following fractures?
Yes
What Age and How did it occur?
Wrist
Arm
Spine
Hip
Other s
ANCESTRY:  Asian  Black  Hispanic  White  Other
MEDICAL /FAMILY HISTORY
Family history of osteoporosis or height loss?  Yes  No
Has either parent had a hip fracture?
 Yes  No
Have you ever smoked?
 Yes  No >>>
Have you quit smoking?
 Yes  No >>>
Do you drink alcohol?
 Yes  No >>>
Do you drink caffeinated coffee, tea or colas?
 Yes  No >>>
Do you avoid milk, dairy products?
 Yes  No >>>
Long-term need for Cortisone/Prednisone?
 Yes  No >>>
Exercise history:  Minimal
 Moderate  Vigorous
Family History of Calcium problems or Kidney stones?  Yes  No
Family History of multiple fractures as a child?
 Yes  No
Number of Packs per Day:
Number of Years:
If yes, how long ago?
Number of Drinks per Day:
Drinks per Week:
Number of Cups per Day:
Number of Years:
If yes, how long?
If yes, how long?
What type?
List all medication (name, dose, frequency, number of months/years):
Name
Dose
#Months/
Years
Frequency
Have you had a BONE DENSITY test before?  Yes  No
Name
Dose
 Yes  No
 Yes  No
 Yes  No
Dosage
Dosage
Dosage
#Months/
Years
If yes, when?___________________________
Do you currently take prescription medications for osteoporosis or have you in the past?
Actonel _______ Fosamax ______ Didronel ______ Boniva ______ Reclast ______ Forteo ______
Strontium Salts______
Do you take calcium?
Do you take Vitamin D?
Do you take Multi Vitamins?
Frequency
Miacalcin ______
Deschutes Osteoporosis Center, LLC
Have you taken any of the following medications?
Steroids (Cortisone or Prednisone)
Seizure Medications
Depoprovera
Lupron
Breast Cancer Medications
Prostate Cancer Medications
YES






NO






Please check specific diseases you have or have had:
 Rheumatoid Arthritis
 Diabetes
 Chronic Diarrhea
 Hyperparathyroidism
 Malabsorption
 Falling our Balance problems
 Removal of stomach or small intestine
 Vision Problems
 Gastric Bypass Surgery
 Epilepsy, Seizures
 Kidney Stones
 Liver Disease
 Cancer/Type ____________________
 Pituitary Disease
 Hyperthyroidism
 Eating Disorder
 Cortisone/Prednisone Use
 Vision Problems
 Amenorrhea (no menstrual periods before
menopause)
 Illness with bed rest (more than one month)
List any other major medical and surgical history not addressed in above lists:
For Women Only
Age you started menstrual cycles _________
Age of Menopause ___________
Have you had menopausal symptoms (hot flashes, mood swings, night sweats)?  Yes  No
Do you now, or have you previously taken Estrogen?  Yes  No
When started?
Have your ovaries been removed?  Yes  No If yes, when (date):
Age
When stopped?
Dosage?