Deschutes Osteoporosis Center, LLC
Name / Account # / Birthdate / Age / SexStreet / Height / Referring Physician
City, State, Zip / Weight / Primary Physician
Phone ( ) / Tallest Height / Today's Date
In the past two weeks, have you had any x-ray studies:
Contrast agent/dye? / Date
Have you ever had any of the following fractures?
Yes / What Age and How did it occur?
Wrist
Arm
Spine
Hip
Other s
ANCESTRY: AsianBlackHispanicWhiteOther
SOCIAL:Marrital Status ; ☐married ☐divorced ☐single ☐widowed ☐significant other
Occupatiion/Retired From______
MEDICAL /FAMILY HISTORY
Family history of osteoporosis or height loss? Yes NoFamily History of Calcium problems or Kidney stones? Yes No
Has either parent had a hip fracture? Yes NoFamily History of multiple fractures as a child? Yes No
Have you ever smoked? Yes NoNumber of Packs per Day: Number of Years:
Have you quit smoking? Yes NoIf yes, how long ago?
Do you drink alcohol? Yes NoNumber of Drinks per Day: Drinks per Week:
Do you drink caffeinated coffee, tea or colas? Yes NoNumber of Cups per Day: Number of Years:
Do you avoid milk, dairy products? Yes NoIf yes, how long?
Long-term need for Cortisone/Prednisone? Yes NoIf yes, how long?
Exercise history: Minimal Moderate VigorousWhat type/how much?
List all medication (name, dose, frequency, number of months/years):
Name / Dose / Frequency / #Months/Years / Name / Dose / Frequency / #Months/
Years
Have you had a BONE DENSITY test before? Yes NoIf yes, when?______
Do you currently take prescription medications for osteoporosis or have you in the past?
Actonel ______Fosamax ______Didronel ______Boniva ______Reclast ______Forteo ______Miacalcin ______Evista_____
Strontium Salts______
Do you take calcium? Yes NoDosage
Do you take Vitamin D? Yes NoDosage
Do you take Multi Vitamins? Yes NoDosage ______
Have you taken any of the following medications?YES NO
Steroids (Cortisone or Prednisone)
Seizure Medications
Depoprovera
Lupron
Breast Cancer Medications
Prostate Cancer Medications
Please check specific diseases you have or have had:
Rheumatoid Arthritis Diabetes Eating Disorder or history
Chronic Diarrhea Hyperparathyroidism Cortisone/Prednisone Use
Malabsorption Falling our Balance problems
Removal of stomach or small intestine Vision ProblemsAmenorrhea(no menstrual periods before
Gastric Bypass Surgery Epilepsy, Seizuresmenopause)
Kidney Stones Liver Disease Illness with bed rest (more than one month)
Cancer/Type ______ Pituitary Disease
Hyperthyroidism
List any other major medical and surgicalhistory not addressed in above lists:
Sytems Review (circle symptoms that apply):
GeneralCardovascularHematology
FeversChest PainEasy Bruising
Night Sweats Irregular Beats Blood Clots
Sweats at rest Racing/Fluttering Anemia
Change in Weightleg or arm swelling
Fatigue
EndocrineNeurologicBone & Joints
Hot FlashesHeadachesBone Pain
Always hot or coldNumbness/TinglingMuscle pain
Blood sugar problems/Diabetes
Thyroid Problems
Breast DischargeSeizuresBack Pain
WeaknessArthritis
GIUrinaryRespiratory
NauseaBlood in urineAsthma Problems
Heartburn/RefluxFrequent UrinationCoughing
Problems SwallowingVery ThirstyShort of Breath
ConstipationIncontinence
Erection difficulty
Diarrhea
Liver Problems
SkinHair & NailsMood etc
RashThinning/baldingDepressed/Sad
HivesBrittle hairAnxious
Red flushingBrittle NailsInsomnia
Acne Excess Hair Growth
Pigment Changes
Daily Food Nutrition
Servings of fruits and/or vegetables______
Servings of whole grains or cereals______
Servings of dairy or calcium foods/milk equivalents______
Servings of proteins/meat/fish/beans/tofu______
Servings of healthy fats or nuts______(for example, omega-3 EFAs, Olive Oil)
Ounces of water or fluids______
For Women Only
Age you started menstrual cycles ______Pregnancies/Biological Children______
Age of Menopause ______
Have you had menopausal symptoms (hot flashes, mood swings, night sweats)? Yes NoAge
Do you now, or have you previously taken Estrogen? Yes NoWhen started? When stopped? Dosage?
Have your ovaries been removed? Yes NoIf yes, when (date):