Bone Densitometry Unit Questionnaire



Bone Densitometry Unit Questionnaire

NAME.................................................................. DATE OF BIRTH..................................

Have you had a bone density scan before at Ashford or St Peters Hospitals? No/Yes

If yes, when did you have your last scan? ...................................................................................

Current height............... Centimetres? Current weight............... Kilograms?

Have you lost height? No/Yes If yes, how much? ............cms

Do you have a family history of osteoporosis? No/Yes

If yes, which relatives?.................................................................................................................

Have they had a hip fracture? No/Yes

Have they had any other fractures? No/Yes

If yes, which bones?.....................................................................................................................

Have you ever had any broken/fractured bones? No/Yes

If yes, please state part of body, how it happened and date of the injury (last 3 fractures).

......................................................................................................................................................

......................................................................................................................................................

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Have you had any hip or spinal operations? No/Yes

If yes, please state part of body and date of operation.................................................................

Have you ever had any radiotherapy (cancer treatment using radiation)? No/Yes

If yes please state the body part and treatment date:....................................................................

Have you ever taken steroid medication (e.g. Prednisolone)? No/Yes

If yes, which of the following applies to you?

Currently taking it (state your medical condition, dose and name of medication) ......................................................................................................................................................

or

Stopped taking it (state why taken, for how long and the date stopped)......................................

…………………………………………………………………………………………..............

Are you or have you been on Hormone Replacement Therapy (HRT)? No/Yes

If yes, which of the following applies to you?

Currently taking it (state dose and type) ……………………………………………………………………………………………..

Have taken it (state for how long and when stopped)…………………………………………..

Are you or have you been on any medication for Osteoporosis (e.g. Calcium or Alendronic Acid) or taking an over the counter Calcium/Vitamin D supplement? No/Yes

If yes, which of the following applies to you?

Currently taking (state name of medication, dose and for how long) …………………………………………………………………………………………………..…………………………………………………………………………………………………..Have taken it (state for how long and date stopped)....................................................................

…………………………………………………………………………………………………..

Please list any other medication you are currently taking and for how long (including dose):

1........................................................... 7.…………………………………….

2........................................................... 8……………………………………..

3........................................................... 9……………………………………..

4........................................................... 10……………………………………

5........................................................... 11……………………………………

6........................................................... 12……………………………………

Do you smoke? No/Yes

For how long?…………………………….Number per day at present …..................................

How many units of alcohol do you consume per week?..............................................................

1 unit=10mls of spirit/half a medium glass of average strength wine (12%)/ half a pint of average strength lager (4%).

Do you have a special diet (e.g. Low calcium, low fat, gluten free or vegan)? No/Yes

If yes please give details………………………………………………………………………...

How much exercise do you do per week, with details of type? (e.g. 20 mins 3 times per week)...............................………………………………………………………………………..…………………………………………………………………………………………………..

FEMALE PATIENTS ONLY

At what age did you have your LAST menstrual period? ......................................................................................................................................................

Have you had a hysterectomy? No/Yes

If yes, how old were you?............................................................................................................

Have you had an Oopherectomy (ovaries removed)? No/Yes

If yes, how old were you?............................................................................................................

WOMEN OF CHILD BEARING AGE ONLY (10-55yrs) We prefer not to do the test if you are pregnant, so please let us know if this is the case. Any woman who is breast-feeding, or who has stopped breast feeding in the last 6 months should contact the Department (01932 722482) for advice before attending for the examination.

There is no reason to believe I am pregnant

Signed (patient)............................................

Confirmed (radiographer)............................

Thank you for taking the time to fill in this questionnaire.

If you are unable to keep the appointment (or if you require any further information) please telephone 01932 722482 as soon as possible.

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