Young Patient Questionnaire for Bone Densitometry at the Yale Bone Center

Patient information:

Name: ______Age: ______

Sex (circle): Female Male Ethnicity: ______

Date of birth: ______

Address: ______

City/Town: ______

Zip Code: ______

( Fill out address only if patient is under 18)

Guardian’s name: ______

Address: ______

______

Phone: Home: ______Best time to call: ______

Work: ______Best time to call: ______

Referring Health Professional: ______

Address: ______

______

Health Survey

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The information from this questionnaire will be summarized in the report to your doctor and will be helpful in interpreting the results of the test. If you are the guardian filling out the questionnaire please answer the following for the patient.

Medications:

1) Please list all of your medications

______

2) Do you take calcium or vitamins if so please list all calcium and vitamins bellow:

______Dosage: ______

How many servings of dairy products do you eat every day?

a) Milk (1 serving = 8 ounce glass) servings per day

b) Yogurt (1 serving = 8 ounces) servings per day

c) Cheese (1 serving = 1 ounce) servings per day

d) Cottage cheese (1 serving = 8 oz) ______servings per day

Please circle YES or NO to the following questions:

3) Are you lactose intolerant? YES NO

4) Do you drink calcium-fortified juices? YES NO

If so, how often and how much?

How often: ______How much: ______

5) Do you now, or have you taken steroids? YES NO

(Glucocorticoids like prednisone, Deltasone, Decadron)?

If yes, which one? ______

Medical History: Please circle YES or NO

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6) Have you ever taken anti-seizure medication? YES NO

If yes, which ones:

______

7) Do you take fluid pills? YES NO

Examples: Lasix (furosemide) or hyrdochlororthiazide?

If yes, which one? ______

8) If you are female, have your periods started? YES NO

If yes, when? ______

9) Has there been a time when you had an irregular period. YES NO

(A period lasting more than 6 months or no periods at all)

If yes when did this happen? ______

10) Have you had any portion of your stomach or intestine surgically removed? YES NO

If yes, what portion? ______When? ______

11) Have you ever taken thyroid medication either for an over- or under active thyroid? YES NO

If yes, what condition? Medication: ______When: ______

12) Have you ever been on long-term heparin or Coumadin therapy? YES NO

13) Have you ever received chemotherapy? YES NO

If yes, what type? ______

Medical history Continued. Please Circle YES or NO

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14) Have you ever smoked? YES NO

15) Do you smoke now? YES NO

16) Do you drink alcohol? YES NO

If yes, how much? ______

17) Have you broken or fractured any bones? YES NO

If yes, which ones? ______How? ______

Do YOU have a:

History of osteoporosis YES NO

Family history of osteoporosis YES NO

History Arthritis YES NO

History Scoliosis of the spine YES NO

History of Diabetes YES NO

History of Inflammatory bowel disease

Example: Crohn’s disease or ulcerative colitis YES NO

History of celiac sprue YES NO

History of cancer YES NO

If yes what kind? ______

History organ transplantation? YES NO

If yes, what organ______When? ______

History of any other chronic disorder? YES NO

If yes, what disorder______

QUESTIONS ABOUT PHYSICAL ACTIVITY

Please list any physical activity you participate in during a typical week in the last month. This includes, walking, running, gym work outs, and any sports.

Activity / Days per Week / Average time spent each Week