Bone density screening questionnaire - NWPC.com

Bone density screening questionnaire
This confidential questionnaire helps us determine your risk factors for osteoporosis.
Please complete and bring it with you bone density screening appointment.
Name:__________________________________ Date:______________
Date of birth:__________________ Age:_______ Ht:_________ Wt:__________ Gender: F M
Ethnicity: Caucasian African-American Hispanic Asian Other
Primary Care Practitioner:_________________
1. Is there any chance that you may be pregnant Yes No
2. Are you right-handed or left-handed Left Right
3. Do you have a perceived height loss Yes No
4. Do you exercise regularly Yes No
5. Do you drink alcohol Yes No
6. Do you smoke Yes No
7. Do you drink coffee Yes No
8. Do you now or have you ever taken Prednisone Yes No
9. Do you have a family history of osteoporosis Yes No
10. Do you have a curvature/scoliosis of your spine Yes No
11. Do you take calcium supplements Yes No If yes, how many mg/day __________
12. Are you post-menopausal Yes No If yes, at what age was your last period ______
13. Have you had surgery:
Hip replacement Yes No If yes: Left Right Both
Both ovaries removed Yes No If yes, when ___________
Lower back Yes No If yes, what was done
14. Please list any other medications you may be on:
15. Have you had this examination before Yes No If yes, when and where___________________
16. Have you had, within the last seven days an
examination where you had contrast material
(Barium study, cat scan, nuclear medicine study): Yes No
Patient initials: __________ Date: __________ Tech initials: ___________ Date: ____________

Northwest Primary Care
PO Box 22075
Milwaukie, OR 97269