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 MEDICAL /FAMILY HISTORY Family history of osteoporosis or height loss? Yes No Has either parent had a hip fracture? Yes No Have you ever smoked? Yes No >>> Have you quit smoking? Yes No >>> Do you drink alcohol? Yes No >>> Do you drink caffeinated coffee, tea or colas? Yes No >>> Do you avoid milk, dairy products? Yes No >>> Long-term need for Cortisone/Prednisone? Yes No >>> Exercise history: Minimal Moderate 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? 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 Yes No Yes No Yes No Dosage Dosage Dosage #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 ______ Strontium Salts______ Do you take calcium? Do you take Vitamin D? Do you take Multi Vitamins? Frequency Miacalcin ______ 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 Cortisone/Prednisone Use Vision Problems Amenorrhea (no menstrual periods before menopause) Illness with bed rest (more than one month) List any other major medical and surgical history not addressed in above lists: For Women Only Age you started menstrual cycles _________ 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 No If yes, when (date): Age When stopped? Dosage?