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Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
This form is for patients who have had a bone density scan in our office.
Please complete the form in it’s entirety – it is important information we need for your bone density scan. If you prefer to print the form and fill it out to bring into the office, you can do so by clicking on
‘PRINT FORM’
below.
PRINT FORM
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Name
*
First
Last
Home Phone
*
Cell Phone
*
Ethnic Group?
*
African American
Asian/Pacific Islander
Caucasian
Hispanic
Native American
Other
If other, please specify.
Date of Birth
*
Gender
*
Email
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
May we contact you for possible participation in research studies?
*
Yes
No
Who ordered this bone density test?
*
Shall we fax copies of your report to any other physician?
*
What is the name of the osteoporosis medication you are taking, if any?
*
When did you start this medication?
If you have previously stopped osteoporosis medication, when did you stop it?
Since your LAST bone density
, have any of the following occurred?
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Are you currently a cigarette smoker?
*
No
Yes
Do you average more than 2 alcoholic drinks per day?
*
No
Yes
Have you been diagnosed with rheumatoid arthritis or thyroid disease?
*
No
Yes
Have you been started on steroids, such as prednisone?
*
No
Yes
Have you had surgery, surgical implants, or hospitalizations?
*
No
Yes
Have you had a fracture (broken bone)?
*
No
Yes
Did your mother or father break a hip?
*
No
Yes
Have you been diagnosed with cancer?
*
No
Yes
Have you had digestive/malabsorptive problems?
*
No
Yes
Have you had changes in your medication(s)?
*
No
Yes
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Please explain.
Technologist Notes:
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Measured Weight:______________
Measured Height:______________
Submit