Patient's Name:      DOB:      Age:

Sex:  SELECT ONEFemaleMale    Medical Record#:      Accession#:

Weight [lbs]:      Height [inches]:      Ethnicity:  SELECT ONECaucasianAfrican AmericanAsianLatinoHispanicOther

		YES	NO
Is there a chance of pregnancy?
Have you taken calcium in the last 24 hours?
Have you taken multivitamins in the last 24 hours?
Have you had a barium x-ray in the last two weeks?
Have you had a nuclear medicine scan or received an injection of contrast dye for a CT or MRI scan in the past week?

		YES	NO
Do you have PRIMARY hyperparathyroidism?
Are you currently going through menopause
Have you gone through menopause
	Was it natural?    If YES, at what age?
	Were your ovaries removed?    If YES, at what age?
Have you had a prior bone density scan?
	If YES, approximate date when scan was done?
	Where?
		YES	NO
Have you had a hip fracture?
	If YES, when?     Which hip? SELECT ONELeftRightBoth
Have you had a spine fracture?
	If YES, when?     Which vertebrae?
Have you ever been told you had a spine fracture visualized on an x-ray?
Have you had any previous fractures other than spine or hip (in your adult life)?
	If YES, which bone was fractured?
	Age when fracture occurred?
Is there any history of hip fractures in mother or father?
Are you a current smoker?
Do you have a history of oral steroid use such as prednisone?
	If YES, at what dose? SELECT ONEless than 5mg5mg or more
	Approximate date when you began steroids?
	For how long? SELECT ONE< 3 months3 to 6 months6 to 12 months1 to 2 years3 to 4 years5 to 10 years> 10 years
Has a physician or healthcare provider ever informed you that you have rheumatoid arthritis?
Do you consume more than two (2) alcoholic beverages in a day?
		YES	NO
Have you ever had spine surgery, such as:
	Laminectomy: if YES, what level? SELECT ONE12345
	Kyphoplasty: if YES, what level? SELECT ONE12345
	Rod Replacement
	Other?    Please explain
Have you ever had hip surgery, such as:
	Hip Replacement? if YES, which hip? SELECT ONELeftRightBoth
	Pinning of a fracture? if YES, which hip? SELECT ONELeftRightBoth
	Other?    Please explain

	Have you taken any of the following in the past 12 months?	YES	NO
Estrogen    SELECT ONEPremarinPremproPrempro loPremphaseCenestinMenestEstraceActivellaFemHRTClimaraOther
NOTE: Vaginal estrogen creams (including Premarin and Estrace) and the vaginal ring (Estring and Phadia) are NOT considered estrogen treatments for osteoporosis.
Calcitonin Nasal Spray    SELECT ONEMiacalcinFortical
Raloxifine - Evista
Teripartide - Forteo
Denosumab - Prolia

	Have you taken any of the following in the past 24 months?	YES	NO
Alendronate - Fosamax
Risedronate - Actonel
Ibandronate - Boniva/oral or iv
Zoledronic Acid - Reclast
Pamidronate - Aredia
Zometa