Scribd Logo
Upload

Welcome to Scribd!

  • 0 views

    DEXA Scan

    Uploaded by

    gayman6790
    Patient questionnaire

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    DEXA Scan

    Uploaded by

    gayman6790
    0 views2 pages
    Patient questionnaire

    Original Title

    DEXA-Scan

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Patient questionnaire

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    0 views2 pages

    DEXA Scan

    Uploaded by

    gayman6790
    Patient questionnaire

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    DEXA Scan PATIENT

    QUESTIONNAIRE

    Please complete this questionnaire while waiting for your bone mineral density test.
    This document will be reviewed with you. A staff member will measure your height and weight.

    Name: ____________________________________________________ Date: _________________________


    Age:______ Date of Birth: _____________________________________ Sex: __ Female __ Male

    If you answer yes to any of the following 3 questions, please speak to the receptionist immediately:
    1. Is there any chance that you are pregnant? __ Yes __ No
    2. Have you had a barium enema or barium drink in the last 2 weeks? __ Yes __ No
    3. Have you had a nuclear medicine scan or x-ray dye in the last week? __ Yes __ No

    The following information will help us to assess your future risk for fracture.
    4. Have you ever had a bone density test before? __ Yes __ No
    If yes, when, and where? _________________________________________________________
    5. Have you ever had surgery of the spine or hips? __ Yes __ No
    6. Have you ever broken any bones? __ Yes __ No
    If yes, please state:
    Bone Broken Age Bone Broke Cause of Broken Bone

    7. Have you taken steroid pills (such as prednisone or cortisone)


    for more than 3 months in the last 12 months? __ Yes __ No
    If yes, are you currently taking steroid pills? __ Yes __ No
    How long have you been taking them? _______________________________________________________________
    What is your current dose? _________________________________________________________________________
    What is the reason you take steroid pills? _____________________________________________________________
    8. Have you ever been treated with medication(s) for osteoporosis? __ Yes __ No
    If yes, which medication(s) and for how long? __________________________________________________________
    _________________________________________________________________________________________________
    9. Is there a chance that you are pregnant? __ Yes __ No
    10. Have you had hyperparathyroidism? __ Yes __ No
    11. Your ethnicity (check one):
    __Black __Aboriginal __Asian __Hispanic __Caucasian (White) __Other
    12. Have you had a recent weight change? __ Yes __ No
    If YES, tell us about it:_____________________________________________________________________________
    13. Have you ever broken a bone?
    If not a simple fall, please describe the
    Bone Broken Simple Fall? circumstances Age when this occurred

    13. Has a parent or sibling had a broken hip from a simple fall or bump? __ Yes __ No
    14. How many times have you fallen in the last year?__________
    15. Have you ever had surgery of the spine, hips, legs or arms? __ Yes __ No
    If YES, describe what type of surgery you had and which side was affected
    ________________________________________________________________________________________________
    16. Are you currently receiving or have you previously received prednisone pills (cortisone)?
    ___ Yes, currently ___ Yes, previously ___ No
    If YES, for how long? ___ What is your dose? ___ mg or ___ pills each day
    17. Have you been treated with any of the following medications?
    Medication Ever? Currently? If current, how long?
    Hormone replacement therapy (Estroqen)
    Tamoxifen
    Raloxifene (Evista)
    Testosterone
    Etidronate (Didronel/Didrocal)
    Alendronate (Fosamax)
    Risedronate (Actonel)
    Intravenous pamidronate (Aredia)
    Clodronate (Bonefos, Ostac)
    Calcitonin (Miacalcin nasal spray)
    PTH (Forteo)
    Zoledronic acid (Zometa)
    Sodium fluoride (Fluotic)
    18. Do you take any calcium supplements (including TUMS)? __ Yes __ No
    19. Do you smoke? __ Yes __ No
    20. Are you still having menstrual periods? __ Yes __ No
    21. Before menopause, have you ever missed your periods for 6 months or more, besides during pregnancy?
    __ Yes __ No
    22. Have you had your menopause? __ Yes __ No
    If yes, at what age? ____
    23. Have you had a hysterectomy? __ Yes __ No Have you had both of your ovaries removed? __ Yes __ No
    If YES, at what age? ____ If YES, at what age? ____

    You might also like