Bone Density Form for Established Patients

Date of Birth

Gender

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

May we contact you for possible participation in research studies?

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?

Are you currently a cigarette smoker?

Do you average more than 2 alcoholic drinks per day?

Have you been diagnosed with rheumatoid arthritis or thyroid disease?

Have you been started on steroids, such as prednisone?

Have you had surgery, surgical implants, or hospitalizations?

Have you had a fracture (broken bone)?

Did your mother or father break a hip?

Have you been diagnosed with cancer?

Have you had digestive/malabsorptive problems?

Have you had changes in your medication(s)?

Measured Weight:______________

Measured Height:______________

Clinical Research