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?

TBS Score:

		YES	NO
Do you have PRIMARY hyperparathyroidism?
Are you currently going through menopause
Have you gone through menopause
	Was it natural? SELECT ONENoYes
	If YES, at what age?
	Were both of your ovaries removed? SELECT ONENoYesUnsure
	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?
	Select the circumstances that best describe how the fracture occurred: SELECT ONEFall/Slip/TripFall from an elevationMotor vehicle accidentNo known traumaOther:FragilityOther:Trauma
	Age when fracture occurred?
	Which hip? SELECT ONELeftRightBoth
Have you had a spine fracture?
	Select the circumstances that best describe how the fracture occurred: SELECT ONEFall/Slip/TripFall from an elevationMotor vehicle accidentCoughNo known traumaOther:FragilityOther:Trauma
	Age when fracture occurred?
	Which vertebrae?
Have you ever had a fracture other than spine or hip as an adult? Do not include fractures of the hands, feet, face and skull.		NoYesUnsure
	Select the circumstances that best describe how the fracture occurred: SELECT ONEFall/Slip/TripFall from an elevationMotor vehicle accidentCoughNo known traumaOther:FragilityOther:Trauma
	Age when fracture occurred?
	Which bone was fractured?
		YES	NO
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: SELECT ONENoYes if YES, what level? SELECT ONE12345
	Kyphoplasty: SELECT ONENoYes if YES, what level? SELECT ONE12345
	Rod Replacement SELECT ONENoYes
	Other? SELECT ONENoYes    Please explain
Have you ever had hip surgery, such as:
	Hip Replacement? SELECT ONENoYes if YES, which hip? SELECT ONELeftRightBoth
	Pinning of a fracture? SELECT ONENoYes if YES, which hip? SELECT ONELeftRightBoth
	Other? SELECT ONENoYes    Please explain
Have you ever had pelvic or abodominal surgery?
	If YES, what was the procedure?
	Approximate date?

	Have you taken any of the following in the past 12 months?	YES	NO
Estrogen Pill or Patch    SELECT ONEOral EstrogenEstrogen skin patch
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 - Zometa
Pamidronate - Aredia