Cardea Hospital Bone Density Center
FRAX Questionnaire
MANDATORY QUESTIONS
No
Yes
Have you gone through menopause (women only)?
No
Yes
Patient survey filled out (below)?
PLEASE INDICATE YES OR NO FOR EACH OF THE FOLLOWING QUESTIONS:
SELECT ONE
Caucasian (White)
African American (Black)
Hispanic
Asian
Other
Please specify your ethnicity?
No
Yes
Have you ever had a prior broken bone after age 20? (don't count broken fingers, toes, or nose)?
No
Yes
Has your mother or father ever broken a hip bone?
No
Yes
Do you
CURRENTLY
smoke (cigarettes or e-cigarettes)?
No
Yes
Do you have 3 or more alcoholic drinks
MOST DAYS
?
No
Yes
Do you have rheumatoid arthritis?
No
Yes
Have you
EVER
taken steroid pills (such as prednisone, dexamethasone) for
LONGER THAN 3 MONTHS?
DOCTORS AT THE CARDEA BONE DENSITY CENTER ALSO DO RESEARCH ON OSTEOPOROSIS.
No
Yes
If you are eligible, may we contact you for research?
Enter the TBS score if you have one. Otherwise leave blank.
TBS Score