DRCTC Patient Form

Diagnostic Radiology Center of the Treasure Coast

Bone Densitometry Patient History

Please complete the following questions to the best of your ability. If you are unsure how to answer, skip it and we will help with the answer when you are seen.

HEIGHT

INCHES

WEIGHT

POUNDS

1. RACE :

AFRO-AMERICAN CAUCASIAN NATIVEAMERICAN ORIENTAL OTHER

2. SEX :

FEMALE MALE

3. HAVE YOU FRACTURED ANY BONES DURING YOUR ADULT LIFE?

Yes No

4. IS THERE A FAMILY HISTORY OF OSTEOPOROSIS?

Yes No

5. DO YOU SMOKE MORE THAN HALF A PACK OF CIGARETTES PER DAY?

Yes No

6. HAVE YOU SMOKED IN THE PAST? IF SO,HOW LONG?

Yes No

7. DO YOU CONSUME DAIRY PRODUCTS DAILY?

Yes No

8. HAVE YOU CONSUMED THREE OR MORE DAIRY SERVINGS PER DAY FOR MOST OF YOUR LIFE?

Yes No

9. DO YOU TAKE A CALCIUM SUPPLEMENT DAILY? IF SO, HOW MUCH?
0-500MG/DAY 501-1000MG/DAY >1000MG/DAY Nothing

10. DO YOU EXERCISE AT LEAST THREE TIMES PER WEEK?

Yes No

11. DO YOU DRINK MORE THAN TWO ALCOHOLIC DRINKS PER DAY?

Yes No

12. HAVE YOU TAKEN ANY OF THE FOLLOWING MEDICATIONS?
STEROIDS (PREDNISONE, CORTISONE, ETC.)
THYROID MEDICATION
ANTICONVULSANT (FOR SEIZURES, EPILEPSY)
Nothing

13. ARE YOU TAKING ANY BONE MINERAL REPLACEMENTS, SUCH AS FOSIMAX, EVISTA, OR MYACALCIN?

Yes No

14. HAVE YOU HAD ANY OF THE FOllOWING CONDITIONS?
PARTIAL OR COMPLETE PARALYSIS
HYPERTHYROIDISM (OVER-ACTIVE THYROID)
KIDNEY DISEASE
RHEUMATOID ARTHRITIS
OTHER ARTHRITIS
PARTOFTHE STOMACH REMOVED
INTESTINAL OR BOWEL DISEASE
Nothing

***** REMAINING QUESTIONS FOR FEMALES ONLY *****

15. HAVE YOU GONE THROUGH MENOPAUSE (CHANGE OF LIFE)?

Yes No

16. DID YOUR MENOPAUSE OCCUR BEFORE AGE 45?

Yes No

17. DO YOU NOW TAKE HORMONES (PREMARIN, ESTROGENS, ETC.)?

Yes No

18. HAVE YOU TAKEN HORMONES, IN THE PAST?

Yes No

19. IF SO, HOW lONG DID YOU TAKE HORMONES?

20. HAVE YOU HAD ANY OF THE FOllOWING SIDE EFFECTS
BREAST SORENESS
HEAVEY PERIODS OR OTHER BLEEDING
HEADACHES
WEIGHT GAIN OR FLUID BUilDUP
OTHER
Nothing

21. DO YOU HAVE AMENORRHEA, NEVER STARTED PERIODS OR ENDED AT A YOUNG AGE?

Yes No

22. HAVE YOU HAD ANY OF THE FOllOWING CONDITIONS?
HYSTERECTOMY (WOMB REMOVED)
OVARIES REMOVED
BLOOD CLOTS (WERE YOU ON HORMONES AT THE TIME?)
BREAST CANCER
FAMILY HISTORY OF BREAST CANCER
CANCER OF THE UTERUS (WOMB)
Nothing

PORT ST. LUCIE FACILITY

FORT PIERCE FACILITY

Diagnostic Radiology Center of the Treasure Coast

Bone Densitometry Patient History