General Questions
What is the patient's tallest height?
SELECT HEIGHT
3' 0"
3' 1"
3' 2"
3' 3"
3' 4"
3' 5"
3' 6"
3' 7"
3' 8"
3' 9"
3' 10"
3' 11"
4' 0"
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' 0"
YES
NO
Has the patient experienced significant HEIGHT loss since last visit?
Has the patient experienced significant WEIGHT loss since last visit?
Fracture History
YES
NO
Fragility fracture(s) since age 45?
Please provide details of bone(s) broken:
SELECT ONE
hip
spine
humerus
wrist
ankle
rib
tibia
femur
pelvis
multiple
SELECT AGE
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
SELECT ONE
hip
spine
humerus
wrist
ankle
rib
tibia
femur
pelvis
multiple
SELECT AGE
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
SELECT AGE
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
Young patient with low trauma fracture(s)?
Please provide details of bone(s) broken:
SELECT ONE
hip
spine
humerus
wrist
ankle
rib
tibia
femur
pelvis
multiple
SELECT AGE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
SELECT ONE
hip
spine
humerus
wrist
ankle
rib
tibia
femur
pelvis
multiple
SELECT AGE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
SELECT AGE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Current and Past Treatment
Nutrition or Medication
Taking NOW
Took in PAST
Taken NEVER
DURATION
Diet high in calcium
year(s)
month(s)
week(s)
day(s)
Calcium supplements
year(s)
month(s)
week(s)
day(s)
Multivitamin
year(s)
month(s)
week(s)
day(s)
Vitamin D Supplement
year(s)
month(s)
week(s)
day(s)
estrogen
year(s)
month(s)
week(s)
day(s)
Fosamax
year(s)
month(s)
week(s)
day(s)
Actonel
year(s)
month(s)
week(s)
day(s)
Boniva
year(s)
month(s)
week(s)
day(s)
Evista
year(s)
month(s)
week(s)
day(s)
Miacalcin
year(s)
month(s)
week(s)
day(s)
Forteo
year(s)
month(s)
week(s)
day(s)
Intravenous Biphosphonate
year(s)
month(s)
week(s)
day(s)
testosterone
year(s)
month(s)
week(s)
day(s)
tamoxifen
year(s)
month(s)
week(s)
day(s)
Didronel
year(s)
month(s)
week(s)
day(s)
Prolia
year(s)
month(s)
week(s)
day(s)
Risk Factors
Indicate which apply to the patient:
Risk Factor
YES
NO
Family hx hip fx
Family hx osteo
Delayed puberty
Eating disorder
COPD
Crohn's disease
Gastric resection/bypass
celiac disease
Rheumatoid Arthritis
Depression
Kidney stones
Kidney failure or dialysis
HIV Infection or AIDS
IDDM
Falls
NOW
PAST
NEVER
Hyperthyroidism
Excess ETOH
Smoking
Hyperpara
Is the patient taking any of the following now or in the past?
Risk Medication
Taking NOW
Took in PAST
Taken NEVER
DURATION
Glucocorticoids
year(s)
month(s)
week(s)
day(s)
Antiepileptics
year(s)
month(s)
week(s)
day(s)
Thyroid Hormone
year(s)
month(s)
week(s)
day(s)
Aromatase inhibitor
year(s)
month(s)
week(s)
day(s)
Androgen deprivation
year(s)
month(s)
week(s)
day(s)
Immune-suppressant
year(s)
month(s)
week(s)
day(s)
Chemotherapy
year(s)
month(s)
week(s)
day(s)
Avandia
year(s)
month(s)
week(s)
day(s)
SSRI antidepressant
year(s)
month(s)
week(s)
day(s)
Proton Pump Inhibitor
year(s)
month(s)
week(s)
day(s)
Does the patient have other medical problems? If YES, please describe:
Questions for women
YES
NO
Premenopausal amenorrhea?
Age under 20?
PRE-Menopausal?
PERI-Menopausal?
POST-Menopausal?
IF YES, At what age?
AGE
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Early surgical menopause?