Bone Mineral Density Questionnaire















MaleFemale

African-American

White, Caucasian

Hispanic

Asian

Other


YesNo


YesNo


YesNo



YesNo


YesNo


PremarinEstrogenBirth Control


YesNo






YesNo


YesNo

YesNo

Fosamax/AlendronateFosamaxBonivaActonelEvistaZometaReclast




1000 mg500 mgNone


YesNo




YesNo




YesNo

Personal history of Osteoporosis

Kidney disease

Hyperthyroid (overactive thyroid)

Parathyroid disorder

Hypothyroid (underactive thyroid)

Rheumatoid arthritis

Eating disorder (Anorexia/bulimia)

Asthma

Celiac Disease

Hypothalamic amenorrhea

Chronic steroid use, type and duration:








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