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Beals_bone_density_form

Osteoporosis Questionnaire
Name: ___________________________________________________________ Date: _________________ Age: _____Sex: _____ Race: _____ Family Background (ie: German): _______________________________ Peak Adult Height: __________ Office use only: Current Height: _______ Weight: __________
Osteoporosis History:
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 Menstrual History:
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? _______________ Medication History:
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
Technician comments:
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Name: _________________________________ D.O.B. ______________ Date _____________________
Medical History:
Have you ever had or currently having any of the fol owing health problems? Please check or answer below.
Exercise History:
How often do you exercise? ________________________ What type of exercise do you usual y do? _________________________________________________________ Smoking:
Do you smoke? Yes: ______ No: _______ If yes, how many packs per day?_____________ How many years? _______________ If you quit, when did you quit? ____________________ Caffeine/ Alcohol:
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? _______________________________

Source: http://bealsinstitute.com/downloads/Beals_Bone_Density_Form.pdf

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