SOUTH TEXAS FRACTURE PREVENTION CLINIC PRE-DEXA PATIENT QUESTIONNAIRE
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- Douglas Griffin
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1 OFFICE USE ONLY SOUTH TEXAS FRACTURE PREVENTION CLINIC PRE-DEXA PATIENT QUESTIONNAIRE PLACE STICKER HERE Name: Date of Birth: Male Female Primary Care Physician Name: Phone Number: Referring Physician Name: Phone Number: 1. Have you lost any height since your 20 s? If so, how many inches? 2. Have you had more than 2 falls in the past year? 3. Have you RECENTLY had a broken bone? If so, where and when? _ Was the break a result of a fall or minor accident? 4. Have you had ANY OTHER broken bones? If so, where? What age? Was the break a result of a fall or minor accident? 5. Have you ever had a bone density (DEXA) test? If so, where and when? 6. Have you had an x-ray with barium, contrast, or a nuclear medicine test within the last 72 hours? 7. Do you usually need to use your arms to assist yourself in standing up from a chair? 8. Have you ever weighed less than 127 pounds since age 18? 9. How active have you been in the last 12 months? Not able to walk Not active (walking less than a mile a day) Somewhat active (walking some but less than 2 miles a day) Very active (walking 2 or more miles a day) 10. Do you have or ever had bone cancer? SURGICAL HISTORY Please list all past surgical procedures and the date. If you have never had any previous surgeries or procedures, check here: 1
2 RISK FACTORS FOR OSTEOPOROSIS 1. Is there anyone in your family who has had osteoporosis or osteopenia? 2. Have your parents, grandparents, or siblings had a hip or spine fracture? 3. Do you smoke cigarettes? If yes, how many per day? 4. Do you drink alcohol? Number of drinks per week? 1 drink = 1 Beer, 1 Glass of wine, 1 Shot of hard liquor 5. Do you have a history of drug abuse? If yes, please explain: 6. MEN: Have you been diagnosed or treated for low testosterone/hypogonadism? a. Have you had your testosterone levels checked? When? 7. WOMEN: a. Age of first menstrual period? b. Is there any way you could be pregnant? c. When you had periods, did you have one each month (unless you were pregnant?) d. Have you had menopause? e. At what age did your periods stop? f. Have you had a total hysterectomy, including removal of ovaries? g. Have you ever taken estrogen or hormone replacement therapy? If yes, how many years? h. Are you on estrogen now? i. Have you had breast cancer? MEDICAL HISTORY Have you ever had any of the following? Alcoholism Chronic liver disease Anorexia Or disordered eating COPD Asthma Chronic Kidney disease Or Kidney stones Kidney dialysis Crohn s disease Depression Gastroesophageal reflux disease Osteogenesis imperfect Spinal cord injury Osteoporosis Osteopenia Thyroid disease Parathyroid disease Pituitary tumor Hypogonadism Rheumatoid arthritis Multiple myeloma Lupus Wegener s Granulomatosis Paget s disease Celiac Disease Diabetes Lactose intolerance Malabsorption Epilepsy Have you ever had cancer? If so, what kind of cancer and when?
3 Have you ever had any radiation treatment? Chemotherapy? Any other conditions: MEDICATIONS & DIETARY SUPPLEMENTS Have you ever taken prednisone (steroid) pills/injections/inhaled? If yes, what was the dose? For how long? Have you ever taken or are you currently taking any of the following? Current Past Current Past Alendronate (Fosamax) Aromatase inhibitor Azathioprine (Azasan or Imuran) Calcitonin (Fortical or Miacalcin) Cyclosporine (Gengraf or Neoral) Denosumab (Prolia) Depo-Provera Digoxin Etidronate (Didronel) Evista (Raloxifene) Exemestane (Aromasin) Goserelin (Zoladex) Heparin (long-term) Ibandronate (Boniva) Letrozole (Femara) Leuprolide (Lupron) Levothyroxine (Synthroid) Multivitamins Oral contraceptives Pamidronate (Aredia) Risedronate (Actonel or Atelvia) Seizure medications Tacrolimus (Prograf) Tamoxifen (Soltamox) Teriparatide (Forteo) Testosterone Vitamin D/Calcium Zolendronic acid (Reclast or Zometa) Heartburn: Current Past Prevacid Prilosec Nexium Diabetes: Current Past Actos Breast Cancer: Current Past Arimidex Antidepressant: Current Past Zoloft Lexapro Prozac Paxil Any other Medications and Supplements:
4 REVIEW OF BODY SYSTEMS Review of Systems: Please check all that apply to you CONSTITUTIONAL: Fever Weight Gain lbs Exercise Intolerance Night Sweats Weight Loss lbs EYES: Dry Eyes Irritation Vision Change EARS, NOSE, MOUTH, THROAT: Difficulty Hearing Ear Pain Frequent Nosebleeds Nose/Sinus Problems RESPIRATORY: Cough Wheezing CARDIOVASCULAR: Chest pain on exertion Arm pain on exertion Skipping of heart beat (palpitations) GASTROINTESTINAL: Abdominal pain Vomiting GENITOURINARY: Urinary loss Difficulty urinating MUSCULOSKELETAL: Muscle aches Muscle weakness SKIN: Abnormal mole Jaundice PSYCHIATRIC: Depression Feel unsafe in a relationship NEUROLOGIC: Loss of consciousness Weakness ENDOCRINE: Fatigue Increased thirst Sore Throat Bleeding Gums Snoring Dry Mouth Shortness of Breath Coughing up blood Change in appetite Black Stools High urinary frequency Blood in urine (hematuria) Arthralgias/joint pain Back pain Eczema Rash Mania Alcohol abuse Numbness Seizures Hair falling out Increased hair growth Oral Abnormalities Mouth Ulcer Teeth Abnormalities Shortness of breath when walking Shortness of breath when lying down Known Heart Murmur Diarrhea Incomplete emptying Sleep disturbances Dizziness Frequent/severe headache HEMATOLOGIC/LYMPHATIC: Swollen glands Bruising Bleeding problems ALLERGIC/IMMUNOLOGIC: Runny nose Sinus pressure Itching Hives Frequent sneezing OFFICE USE ONLY Height: Weight: BP: P: OFFICE USE ONLY PLACE STICKER HERE
5
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2. Have your symptoms affected your ability to carry out your daily activities? YES NO
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Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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Laser Vein Center Thomas Wright MD Page 1 of 4
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New Patient Medical History Form
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Eastern Shore MediCann Clinic, LLC
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Symptom Review (page 1) Name Date
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