Deschutes Osteoporosis Center, LLC

Deschutes Osteoporosis Center, LLC

Name / Account # / Birthdate / Age / Sex
Street / 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: AsianBlackHispanicWhiteOther

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 ProblemsAmenorrhea(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):