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Name: ___________________________________________________________ Date: _________________
Age: _____Sex: _____ Race: _____ Family Background (ie: German): _______________________________
Peak Adult Height: __________ Office use only: Current Height: _______ Weight: __________
Have you ever had a bone density test before? Yes: _____ No: _____
If yes, when and where did you have it? _________________________________________
Did your previous bone density scan diagnose you with osteopenia or osteoporosis? Yes: _____ No: _____
Are you currently on any medications for osteoporosis? (Circle) Fosamax 35mg, Fosamax 70mg, Fosamax 70mg
+ Vit D (2800), Fosamax 70mg + Vit D (5600), Actonel 35mg, Actonel 75mg, Actonel 150mg, Atelvia 35mg,
Miacalcin, Fortical Nasal Spray, Estrogen, Evista, Boniva 150mg, Boniva 3mg IV, Reclast IV, Forteo SQ, or
Have you discontinued any osteoporosis medications? Yes: ____ No: ____ If yes, list name of medication and
why you discontinued it. ____________________________________________________________________
Do you have a family history of osteoporosis? Yes: _______No: ______ Relationship: ___________________
Bone Fracture History:
Have you ever fractured or broken a bone after the age of 40 yrs? Yes: ______ No: _______
If yes, what bone(s) was fractured _____________and was it a fragility/stress fracture or traumatic fracture due to
Age of first period: ________ Are you stil menstruating? Yes:______ No:______
If yes, are your periods regular or irregular? (Circle). If no, age of onset of menopause _________.
Was menopause natural or did you have surgical removal of your uterus and/or ovaries? (Circle)
Do you have symptoms associated with menopause, such as hot flashes, sleeplessness, headache, or lack of
concentration? Yes: ______ No: ______.
If menopausal, were you started on hormones (estrogen, or estrogen and progesterone)?
If yes, how soon after menopause did you start taking hormones? ____________Are you stil taking hormones?
Yes: ______ No: ______. If not how long did you take them before stopping? __________________
Have you ever or are you currently taking any hormone suppressing agents? ( ie: Lupron, Depo Provera)
Yes: ____No: ____ If yes, how long? _______________
Current, long term or past use of steroid therapy (prednisone, orisone, deltasone, solumedrol,etc.)?
Yes: ____No: ____. If yes please explain________________________________________________________
Antiseizure drugs such as Dilantin or Phenobarbital over 5 years? Yes: ____No: ____
PLEASE CONTINUE ON THE BACK
Name: _________________________________ D.O.B. ______________ Date _____________________
Have you ever had or currently having any of the fol owing health problems? Please check or answer below.
How often do you exercise? ________________________
What type of exercise do you usual y do? _________________________________________________________
Do you smoke? Yes: ______ No: _______ If yes, how many packs per day?_____________
How many years? _______________ If you quit, when did you quit? ____________________
How many servings of caffeinated beverages do you drink per day? __________ Type (ie: coffee, soda)_______
Do you drink alcohol on a daily basis? Yes: ______ No: _______If yes, how many drinks per day? ____________
Calcium and Vitamin D Assessment:
How many servings of calcium rich foods do you average per day? _________________
Do you take a calcium supplement? Yes: ________ No: __________
If yes, how many mil igrams per day?: _____________
Does your calcium contain vitamin D or do you take vitamin D? Yes: _________ No: __________
If yes, how many IU of vitamin D per day?: __________
Do you take a multi vitamin? Yes: ______ No: _______ If yes, what kind? _______________________________
Olive Healthcare – Soft Gelatin Capsule Product List At Olive Healthcare we have a healthy pipeline of new formulations secondary to our commitment to Research & Development in the soft gelatin field. The products listed below can be modified as per the requirements of our customers keeping in mind the therapeutic windows for each ingredient. The products are listed below in accordance
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