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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