Have you ever had a bone density test in the past? YES / NO If yes, when, where and what type (DXA, ultrasound or QCT)?

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1 Dated 5/09 Colorado Center for Arthritis & Osteoporosis Bone Health Evaluation/New Patient Information Form Date of first appointment: LAST FIRST M.I. Date of birth: Address: Age: Sex: STREET Apt. # CITY STATE ZIP Phone(s): Home : Cell: Work: Referred by (circle one): Self Family Friend Physician Other health professional Name of person making referral: Name of primary care provider (general or family doctor): A referral letter will be sent to your primary care provider and to the physician who referred you (if any). Please list any other people that you would like to receive a letter below: Address: Address: Bone Health Review Have you ever had a bone density test in the past? YES / NO If yes, when, where and what type (DXA, ultrasound or QCT)? > Have you ever been told that you have osteoporosis or thin bones? YES / NO Have you ever broken a bone? YES / NO If yes, when and which bone? Please describe the circumstances: > How tall were you at your tallest? Have you lost height? YES / NO If yes, how much? Is there any chance that you could be pregnant? YES / NO Have you had any x-ray or nuclear medicine studies in the last week? YES / NO Have you had any back or hip surgeries in the past? YES / NO Do you have (circle): Scoliosis Back arthritis Hip arthritis > Do you have back pain? YES / NO How old were you when you went through menopause (if applicable)? If you have had a hysterectomy, when? Were your ovaries removed? YES / NO Have you ever smoked on a regular basis? YES / NO How long? How many packs per day? For how many years? Do you still smoke? YES / NO How many alcoholic beverages per day on average? > Have you ever taken prednisone or similar steroid for more than a few weeks at a time? YES / NO If so, give details as to when, how much, for what reason and for how long? Does anyone in your family have osteoporosis? YES / NO If so, who? Did either of your parents suffer from hip fracture? YES / NO Have you ever been diagnosed with low testosterone (men)? YES / NO Rheumatoid arthritis? YES / NO Type I diabetes? YES / NO Liver disease? YES / NO Hyperthyroidism (high thyroid)? YES / NO Hyperparathyroidism (high parathyroid)? YES / NO OFFICE USE: Ht: Wt: Handedness: Pregnant: YES / NO VFA indication:

2 Systems Review General: Eyes: Ears: Nose: Mouth: Recent weight gain (Intentional? Y / N Amount: ) Over what period? Recent weight loss (Intentional? Y / N Amount: ) Over what period? Fatigue Fever Night sweats Hot flashes Pain ( L R ) Redness ( L R ) Loss of vision ( L R ) Double vision Blurred vision Dryness Itching eyes Ringing in ears ( L R ) Loss of hearing ( L R ) Frequent nosebleeds Dryness of nose Dryness Premature tooth loss Throat: Lungs: Heart: Frequent sore throats Hoarseness Difficulty swallowing Shortness of breath Cough Coughing up blood Wheezing Loud snoring Chest pains Irregular heart beat Fluid retention in legs or feet Heart murmurs Fingers or toes turn blue/white in the cold Stomach and intestines: Nausea Vomiting Vomiting of blood or coffee ground material Heartburn Stomach pains Diarrhea Constipation Blood in stools Black stools Urinary and reproductive: Men only: Difficulty beginning urination Difficulty emptying bladder completely Pain or burning on urination Frequent urination Urination during the night (# of times ) Blood in Urine Genital rashes or ulcers Difficulty with erections Loss of libido Women only: Age at which periods began If you are still having periods: Periods regularly spaced? Y How many days apart? Blood/Lymph: Anemia Low white blood cells Low platelets Bleeding tendency Easy bruising Blood clots N Transfusion (Year: ) Swollen glands (lymph nodes) Nervous System: Headaches Dizziness Fainting/Loss of consciousness Seizures Numbness or tingling of hands Numbness or tingling of feet Memory loss Difficulty concentrating Difficulty with balance/falling Difficulty falling asleep Difficulty staying asleep Psychiatric: Anxiety Suicidal thoughts Hallucinations Skin: Rash Hives Sun sensitivity Tightness of skin Sores or ulcers Nodules or bumps Hair loss Endocrine: Intolerant of cold Intolerant of heat Allergic/Immunologic: Hay fever Recent infection Persistent infections Muscles/Bones /Joints: Muscle weakness Muscle tenderness Morning stiffness Lasting how long? Minutes / Hours Joint pain Back Pain Joint swelling Joint redness Joints affected in the last 6 months: 2

3 Rheumatologic History At any time, have you or a blood relative had any of the following? (check all that apply) yourself (X) Osteoarthritis Relative (list relationship) yourself (X) Lupus relative (list relationship) Rheumatoid arthritis Ankylosing spondylitis Gout Childhood arthritis Arthritis (unknown type) Osteoporosis Fibromyalgia Other arthritis conditions: Personal medical history Have you ever had: Cancer (type) Heart problems Kidney disease Eating disorder Epilepsy/seizures Celiac disease Asthma Underactive thyroid Cystic Fibrosis High cholesterol Cataracts Overactive thyroid Emphysema Stroke High Blood Pressure Diabetes Psoriasis Stomach ulcers Infertility Other significant illness or bowel disease: Surgical history Type of operation Year Reason Any serious injuries/accidents? Y N Describe: Are you prone to falls? Y N Describe: Medications Do you have medication allergies? If yes, to what (also describe your reaction)? Have you ever taken heparin, anti-seizure medications, lithium, or Depo Provera? (please circle if so) Present medications (include vitamins, supplements and over-the-counter medications) 3

4 Name of medication Strength Times per day Date started How much did it help? A lot Some Not at all Calcium intake (please make your best guess at average amounts) Number of glasses of milk per day: Number of cups of yogurt or ice cream per day: Number of servings of cheese per day (1 serving = 1 slice = 1 oz.): Calcium supplements: Type: Milligrams per tablet: Number per day: Have you taken a calcium supplement TODAY? YES / NO Are you taking now or have you ever taken any of the following medications for osteoporosis prevention or treatment? Fosamax (alendronate) Dose: Started: Stopped: Actonel (risedronate) Dose: Started: Stopped: Boniva (ibandronate) Dose: Started: Stopped: Forteo (teriparatide) Dose: Started: Stopped: Reclast (zolendronate) Dose: Started: Stopped: Evista (raloxifene) Dose: Started: Stopped: Estrogen Dose: Started: Stopped: Miacalcin (nasal calcitonin) Dose: Started: Stopped: Other: Medication/dose: Started: Stopped: 4

5 Habits How many cups of coffee do you drink per day? How many sodas do you drink per day? Do you use any street drugs or any prescription drugs for non-medical reasons? If so, which drugs? Have you ever used IV drugs? Do you exercise regularly? If so, describe your exercise routine: Social History Where were you born: Marital status (circle one): Never married Married Widowed Divorced Separated Domestic partnership Spouse/significant other name: Major illnesses of spouse: Who besides yourself lives in your house: Type of housing: Do you have stairs to climb at home? If so, how many? Circle highest educational level: College: Grad. school Occupation: Presently employed? Number hours per week: Family History Father Mother If living If deceased Age Health Age at death Cause Number of brothers Number living Number of sisters Number living Serious illnesses in siblings Number of children Number living Ages: Serious illnesses in children Do you know of any blood relative who has had (give relationship): Cancer (list type) Heart problems High blood pressure Stroke Asthma Bleeding tendency Alcoholism Psoriasis Diabetes 5