The Osteoporosis Center at St. Luke s Hospital Desloge Outpatient Center (on the west side of 141) 121 St. Luke s Center Drive, Suite 504 Chesterfield, MO 63017 Phone 314 205-6633 Fax 314 590-5909 NEW PATIENT QUESTIONNAIRE Legal Name: Ethnic/racial background: Date of Birth: Gender: _ Referring physician: Reason for visit: Have you ever broken or fractured a bone (including compression fractures of the spine)? Yes No If yes, please list below. Bone broken Age/Year How did it happen? Have you been treated with any of the following medications? Yes No If yes, please check below and provide approximate start/stop dates (month/year or just year). This is an important part of your history. Please be as complete as possible. Start Alendronate (Fosamax) Risedronate (Actonel, Atelvia).... Ibandronate (Boniva)... Zoledronic acid infusions (Reclast/Zometa).. Pamidronate infusions (Aredia) Etidronate (Didronel) Raloxifene (Evista) Teriparatide injections (Forteo). Abaloparatide injections (Tymlos). Denosumab injections (Prolia). Calcitonin (Miacalcin, Fortical)..... Stop Page 1 of 6
Patient s name_ Do you have any of the following calcium-rich foods regularly? Yes No If yes, please estimate your intake. Include serving size and frequency (e.g., 8 oz daily). Milk Yogurt Cheese Calcium-fortified orange juice Soy milk Other Do you take calcium supplements? Yes No If yes, how much? Do you take a multivitamin? Yes No Do you take vitamin D that is not included in your calcium supplements or multivitamin? Yes No If yes, how much? Do you exercise regularly? Yes No If yes, what do you do and how often? FOR WOMEN ONLY: How old were you when you first got your menstrual period? Have you ever been pregnant? Yes No If yes, how many pregnancies? How many live births? Have you gone through menopause (has it been over 12 months since your last menstrual period)? Yes No If yes, how old were you when you went through menopause? Have you had your uterus and/or ovaries removed? Yes No If yes, please specify surgery and year. Have you taken hormone therapy? Yes No If yes, please specify dates. FOR MEN ONLY: Have you had problems with erectile dysfunction? Yes No Do you have a history of testosterone deficiency? Yes No Page 2 of 6
Patient s name_ Have you ever been treated with prednisone or other steroids? Yes No If yes, please indicate number and duration of courses. What was your peak height as a young adult? Have you had any falls in the last year? Yes No Do you drink soda or caffeine regularly? Yes No If yes, what and how much? MEDICATIONS: Please list all current medication directly on this document. Please do not attach a separate medication list. This document will be scanned into your electronic medical record. 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10. _ PAST MEDICAL HISTORY: Do you have or have you had any of the following? If yes, please check. Alcoholism Anorexia Atrial fibrillation Barrett s esophagus Blood clot (DVT/PE) Cancer Celiac disease Crohn s disease Cushing s syndrome Esophageal stricture/dilation Intestinal surgery Kidney disease Kidney stones Lactose intolerance Mulitple myeloma Multiple sclerosis Parathryoid disease Radiation therapy Rheumatoid arthritis Scoliosis Seizures Stomach surgery Stroke Thyroid disease Ulcerative colitis Upper GI bleed Page 3 of 6
Patient s name_ Please list any other medical problems that you have been diagnosed with by a medical professional (e.g., high blood pressure, high cholesterol, diabetes, heart disease, COPD, asthma, etc). 1. 2. 3. 4. 5. 6. 7. ALLERGIES: Are you allergic to any medications? Yes No If yes, list the name of the medication and the type of reaction you had. 1. 2. 3. Do you have other allergies? If yes, please specify. PAST SURGICAL HISTORY: Have you had any operations? List the surgery and year. SURGERY Year 1. 2. 3. 4. 5. HOSPITALIZATIONS: Have you been hospitalized? List the reason and year. REASON Year 1. 2. 3. 4. Page 4 of 6
Patient s name_ FAMILY HISTORY: Mother Living Deceased Year of birth (if living) or Age at death Major Medical Problems/Cause of Death Father Living Deceased Siblings Children # brothers # sisters # sons # daughters Has a parent, sibling or child suffered a hip, spine or other major fracture as an adult? Yes No If yes, please specify. Has a family member developed a deep vein blood clot or pulmonary embolism? Yes No If yes, please specify. Do you have a family history of breast cancer? Yes No If yes, please specify. Other important family history: SOCIAL HISTORY: Tobacco Status: current smoker, # cigarettes per day former smoker, when did you quit? never smoker Alcohol Screening: Did you drink alcohol in the last year? Yes No If yes, please specify: How many drinks per week or month on average? How many drinks on a typical day? Marital Status: Single Married Divorced Widowed Partnered Page 5 of 6
Patient s name_ REVIEW OF SYSTEMS: Are you having problems with the following? CARDIOVASCULAR Chest pain Yes No Swelling in legs Yes No Palpitations Yes No Heart problems Yes No CONSTITUTIONAL Unexplained weight loss Yes No Unexplained weight gain Yes No Fatigue Yes No Poor appetite Yes No ENT Hearing loss Yes No Dentures Yes No Mouth ulcers Yes No Needing dental work Yes No EYES Cataracts Yes No Change in vision Yes No GASTROINTESTINAL Constipation Yes No Diarrhea Yes No Stomach Ulcers Yes No Problems swallowing Yes No Heartburn Yes No GENITOURINARY Blood in urine Yes No Incontinence Yes No MUSCULOSKELETAL Joint pain Yes No Back pain Yes No Thigh pain Yes No Other pain Yes No NEUROLOGY Dizziness Yes No Poor balance Yes No PSYCHIATRIC Depression Yes No Anxiety Yes No RESPIRATORY Cough Yes No Shortness of Breath Yes No SKIN Skin changes Yes No Rashes Yes No Hives Yes No MEN ONLY Problems with erections Yes No History low testosterone Yes No WOMEN ONLY Hot flashes Yes No Night sweats Yes No _ Patient Signature _ Physician Signature Date Date Page 6 of 6