[wr_row width=”boxed” background=”none” solid_color_value=”#FFFFFF” solid_color_color=”#ffffff” gradient_color=”0% #FFFFFF,100% #000000″ gradient_direction=”vertical” repeat=”full” img_repeat=”full” autoplay=”yes” position=”center center” paralax=”no” border_width_value_=”0″ border_style=”solid” border_color=”#000″ div_padding_top=”10″ div_padding_bottom=”10″ div_padding_right=”10″ div_padding_left=”10″ ][wr_column span=”span12″ ][wr_heading el_title=”Bone Mineral Density Questionnaire” tag=”h2″ text_align=”center” heading_margin_top=”25″ heading_margin_bottom=”25″ font=”inherit” enable_underline=”yes” border_bottom_style=”solid” appearing_animation=”0″ disabled_el=”no” ]Bone Mineral Density Questionnaire[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] Name Today’s Date Date of Birth Patient Phone Number Referring Physician Name: Physician Phone Number Sex: MaleFemale Ethnic Origin: African-American White, Caucasian Hispanic Asian Other Gynecological History Have you gone through menopause? YesNo Have you had a hysterectomy? YesNo Have you had your ovaries removed? YesNo Absence of menstruations (i.e. loss of period other than pregnancy or menopause)? YesNo Do you take hormone therapy in any form at this time? YesNo If so, what type? (Check that applies.) PremarinEstrogenBirth Control Medical History Have you ever had a Bone Density (DXA) scan before? YesNo If so, when? Where? Do you have a family history of Osteoporosis? YesNo Have you taken Cortisone or Prednisone orally for over 3 months? YesNo Do you take any medication for raising bone density? YesNo Fosamax/AlendronateFosamaxBonivaActonelEvistaZometaReclast If so, how long? Do you take supplemental calcium? 1000 mg500 mgNone Do you take supplemental vitamin D? YesNo If so, How much? Have you had hip replacement surgery? YesNo If so, which one? Have you had surgery on your lower back? YesNo Other Medical conditions: (Check all that apply) 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: Current Height: Previous Height: Current Weight: [/wr_text][/wr_column][/wr_row espanolcialis.net]
