DEXA questionnaire

Bone density testing for osteoporosis is done in the privacy of our office using the latest DEXA bone densinometer. This test is for the detection of osteoporosis by using the minimum amount of radiation.

To determine if you are at risk for osteoporosis please fill in and print out the questionnaire below, or have the information available at the time of your test.

Date:
Name:
Present Age:

What is your ethnic background?	Asian Black/African American Caucasian Hispanic Native American/American Indian
	YES	NO
Have you had a previous bone density test?			If yes, when & where?
Do you engage in any exercise activity?			What?
Do you smoke?			How much? How long?
Is your diet low in dairy products/calcium?
Have you ever had a bone fracture?			If yes, what kind?
Do you have a history of kidney stones?			Please Explain
Do you have a family history of osteoporosis?			Who?
Do you have a family history of breast cancer?			Who?
At what age did you start your periods?			Where they regular? Yes No
Have you started menopause?			When? (year)
Have you finished menopause?			When? (year)
Have you had a hysterectomy?			At what age? Were ovaries removed?
Are you on thyroid medications?			Dosage: How long?
Are you on steroid or Prednisone medication?			Dosage: How long?
Have you ever been on steroid or Prednisone medication?			When? How long?
Did you ever take a birth control pill?			At what age? How long?
Are you on estrogen medication now?			For how long? Name of hormone replacement:
Are you taking Actonel now?			For how long?
Were you ever on Actonel & stopped taking it?			If yes, why?
Are you taking Evista now?			For how long?
Were you ever on Evista & stopped taking it?			If yes, why?
Are you taking Fosamax now?			For how long?
Were you ever on Fosamax & stopped taking it?			If yes, why?
Are you using Miacalcin nasal spray?			For how long?
Have you ever tried Miacalcin nasal spray & stopped using it?			If yes, why?
Do you take a multivitamin daily?			If yes, for how long?
Do you take Vitamin D?			If yes, for how long?
Do you take calcium supplements (ex Tums)?			What kind? If yes, amount daily? For how long?
What medications are you taking now?
What is your height?			What is your weight?
Have you lost any height?			Explain:
Who is your primary care physician?