BONE DENSITOMETRY SCREENING

 

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PATIENTS NAME:

Date:

DOB:

Age:

SEX:

M

F

SSN:

REFERRING PHYSICIAN:

PHONE #:
       

Is this your first bone density study?

 Yes No

If NO, when and where was your last test completed:
 

*Ethnic background:

Caucasian

 African American Hispanic Asian Other

*Asian and Caucasian women have the highest risk for developing osteoporosis.  African American and Hispanic women have a lower but still significant risk.
 

Date of last menstrual period:

Could you be pregnant?

 Yes No
 

Current Weight:

 Height: Age at Menopause:

Are you taking hormone replacement?

 Yes No Specify:

List current medications:

Do you have any of the following?

Asthma

 Yes No Thyroid Disorder Yes No

Kidney Disorder

 Yes No Scoliosis Yes No

Previous fractures

 Yes No      

If Yes, list body part and approximate date:

Do you take calcium supplements?

 Yes No Did you take any today? Yes No

If yes, how much daily?

 0-500 mg   500-1000mg    

Do you use dairy products?

 Yes No      

If yes, what and how much daily?

Do you have a family history of osteoporosis?

Yes

No
 

Were you ever a smoker?

Yes

No

If you stopped, when?
 

I verify that the answers I have provided to the questions on this form are correct and understand that withholding information or inaccurate information may adversely affect the interpretation of this exam.

Patients signature:
 

Date:

Technologist comments:
 

Technologist initials:

Date:
 
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