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).
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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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