| | 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? | | |
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? | | |
| Approximate date when you began steroids? | | |
| For how long? | | |
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? | | |
| Kyphoplasty: if YES, what level? | | |
| Rod Replacement | | |
| Other? Please explain | | |
Have you ever had hip surgery, such as: | | |
| Hip Replacement? if YES, which hip? | | |
| Pinning of a fracture? if YES, which hip? | | |
| Other? Please explain | | |