Deschutes Osteoporosis Center, LLC
Name
Account #
Birthdate
Street
Height
Referring Physician
City, State, Zip
Weight
Primary Physician
Tallest Height
Today's Date
Phone (
)
Age
Sex
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
Has either parent had a hip fracture?
Have you ever smoked?
Have you quit smoking?
Do you drink alcohol?
Do you drink caffeinated coffee, tea or colas?
Do you avoid milk, dairy products?
Long-term need for Cortisone/Prednisone?
Exercise history:  Minimal
 Moderate
 No
 Yes  No
 Yes  No>>>
 Yes  No>>>
 Yes  No>>>
 Yes  No>>>
 Yes  No>>>
 Yes  No>>>
 Vigorous
Family History of Calcium problems or Kidney stones?  Yes  No
Family History of multiple fractures as a child?
 Yes  No
Number of Packs per Day:
Number of Years:
If yes, how long ago?
Number of Drinks per Day:
Drinks per Week:
Number of Cups per Day:
Number of Years:
If yes, how long?
If yes, how long?
What type/how much?
List all medication (name, dose, frequency, number of months/years):
Name
Dose
#Months/
Years
Frequency
Have you had a BONE DENSITY test before?  Yes  No
Name
Dose
Frequency
#Months/
Years
If 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?
Do you take Vitamin D?
Do you take Multi Vitamins?
 Yes  No
 Yes  No
 Yes  No
Dosage
Dosage
Dosage ________________________
Deschutes Osteoporosis Center, LLC
Have you taken any of the following medications?
Steroids (Cortisone or Prednisone)
Seizure Medications
Depoprovera
Lupron
Breast Cancer Medications
Prostate Cancer Medications
YES






NO






Please check specific diseases you have or have had:
 Rheumatoid Arthritis
 Diabetes
 Chronic Diarrhea
 Hyperparathyroidism
Malabsorption
 Falling our Balance problems
 Removal of stomach or small intestine
 Vision Problems
 Gastric Bypass Surgery
 Epilepsy, Seizures
 Kidney Stones
 Liver Disease
Cancer/Type ____________________
 Pituitary Disease
 Hyperthyroidism
 Eating Disorder or history
 Cortisone/Prednisone Use
 Amenorrhea(no menstrual periods before
menopause)
 Illness with bed rest (more than one month)
List any other major medical and surgicalhistory not addressed in above lists:
Sytems Review (circle symptoms that apply):
General
Fevers
Night Sweats
Sweats at rest
Change in Weight
Fatigue
Cardovascular
Chest Pain
Irregular Beats
Racing/Fluttering
leg or arm swelling
Hematology
Easy Bruising
Blood Clots
Anemia
Endocrine
Hot Flashes
Always hot or cold
Blood sugar problems/Diabetes
Thyroid Problems
Breast Discharge
Neurologic
Headaches
Numbness/Tingling
Bone & Joints
Bone Pain
Muscle pain
Seizures
Weakness
Back Pain
Arthritis
GI
Nausea
Heartburn/Reflux
Problems Swallowing
Constipation
Urinary
Blood in urine
Frequent Urination
Very Thirsty
Incontinence
Erection difficulty
Respiratory
Asthma Problems
Coughing
Short of Breath
Diarrhea
Liver Problems
Skin
Rash
Hives
Red flushing
Acne
Pigment Changes
Hair & Nails
Thinning/balding
Brittle hair
Brittle Nails
Excess Hair Growth
Mood etc
Depressed/Sad
Anxious
Insomnia
Deschutes Osteoporosis Center, LLC
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  No
Do you now, or have you previously taken Estrogen?  Yes  No
When started?
Have your ovaries been removed?  Yes NoIf yes, when (date):
Age
When stopped?
Dosage?