Tri-County Endocrinology and Nuclear Medecine - Sterling ...
Osteoporosis Questionnaire
1. What is your ethnicity?
□Caucasian □Afro-American □Asian □American-Indian
□Hispanic □Polynesian □Indian Other _____________________
2. Have you ever broken any bones? □Yes □No □Unknown
If yes, which bones and at approximately what age?
Vertebra (spine)
Wrist: Right _____ Left _____
Hip: Right _____ Left _____
Hip Replacement: Right _____ Left _____
Other: ______________________
3. Do you have Scoliosis? □Yes □No □Unknown
4. Is there osteoporosis in your family? □Yes □No □Unknown
If yes, what relation(s) __________________
5. Is there breast cancer in your family? □Yes □No □Unknown
6. What was your maximum height? _____________________
How tall are you now? ______________________________
7. When, or at what age did your menopause (last period) occur? ____________________
8. Have you ever been pregnant? □Yes □No
9. Have you ever had any children? □Yes □No
If yes, how many? _________________
10. Have you ever taken oral contraceptives? □Yes □No
If yes, for how many years? ______________
11. Have you taken estrogen therapy post-menopause? □Yes Now □Yes Past □No
(Premarin, Prempro, Ogen, Estrace, Estraderm, etc.)
If yes, for how many years? _________________
12. How many servings of dairy products do you consume a day? ____________
(one serving = 8oz milk, 1 oz cheese, 1 cup yogurt/ice cream, 4oz cottage cheese)
Did you consume three or more dairy
servings daily as a teenager and young adult? □Yes □No □Unknown
13. Do you take calcium supplements? □Yes □No □Unknown
If yes, list the name, dosage and how often you take it.
14. Do you take a vitamin D preparation? □Yes □No □Unknown
If yes, list the name of the preparation, dosage and how often you take it.
15. Do you exercise at least 3 times a week? □Yes □No □Unknown
16. Have you ever smoked? □Yes □No □Unknown
If yes, how many cigarettes a day? ___________
How many years did you smoke? ____________
17. Do you drink alcoholic drinks nearly every day? □Yes □No □Yes Past
If yes, how many drinks / day? ________
For how many years? _______
18. Is your salt (sodium) intake high? □Yes □No □Yes Past
19. Is your coffee (caffeine) intake high? □Yes □No □Yes Past
1-3 coffee cups / day ______
Above 3 cups a day ______
20. Is your soft drink intake high? □Yes □No □Yes Past
Less than 12 ounces / day _____
12-36 ounces / day ____
21. Have you fallen down frequently? □Yes □No □Yes Past
22. Do you feel unsteady on your feet? □Yes □No □Yes Past
23. Have you taken any of the following medications?
a. Thyroid □Yes □No □Yes Past
(eg: Thyroxine, Synthroid ,Cytomel,
Levothroxine, Levoxyl, Armour thyroid)?
Name of preparation ______________
Dosage and frequency _____________
b. Steroids (prednisone, Cortisone, etc) □Yes □No □Yes Past
Name of preparation ______________
Dosage and frequency _____________
c. Anticonvulsants (for seizures, epilepsy) □Yes □No □Yes Past
Dilantin _____ Phenobarb _____ Other _____
If yes, for how many years _____
d. Lasix (furosemide), Demadex or Bumex □Yes □No □Yes Past
e. Thiazide (Hyrodiuril, □Yes □No □Yes Past
Hydrochlorothiazide, Dyazide, Maxzide, etc.)
24. Have you ever taken any of the following
medications for osteoporosis?
Actonel □Yes □No □Yes Past
Fosamax □Yes □No □Yes Past
Boniva □Yes □No □Yes Past
Evista □Yes □No □Yes Past
Miacalcin □Yes □No □Yes Past
Nolvadex (tamoxifen) □Yes □No □Yes Past
Forteo □Yes □No □Yes Past
Reclast □Yes □No □Yes Past
25. Have you had any of the following conditions?
If so, please circle the letter(s)
a. Partial of complete paralysis (eg. Stroke, CVA)
b. Hyperthyroidism (over active thyroid)
c. Kidney stones
d. Kidney disease or failure: If yes, have you been on dialysis?
e. Rheumatoid arthritis
f. Hyperparathyroidism (high blood calcium)
g. Intestinal (bowel) disease or malabsorption (colitis, Crohn’s)
h. Surgical bowel resection or bypass surgery for obesity
i. Liver disease
j. Pernicious anemia
k. Anorexia nervosa or bulimia
l. Part of stomach removed (ulcer surgery)
m. Breast cancer
n. Hysterectomy
o. Ovaries removed: If yes, at what age?
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