Bone Density Test Form
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1BONE DENSITY
Bone Density Test
Please report to the lower level of our office building for this test.
Patient MR#:
Patient ID (PM) #:
Name:
Date of Birth:
PCP: Dr.
Please place a check beside the following risk factors for Osteoporosis if they apply to you.
Age at Menopause?
Is this your First Scan ?
Is this a follow-up scan?
Are you female?
Are you 65 of age or over?
Are you Caucasian (white)?
Have you reached menopause?
Have you had a hysterectomy?
Have you had a prior fracture of the hip, spine, or forearm? If yes please circle the ones that apply
Do you experience repeated falls?
Are you a current tobacco user?
Do you have severe visual impairment?
Do you drink more than one alcoholic beverage a day?
Do you receive an inadequate amount of exercise?
Do you consider your overall condition poor?
Do you have a family history of Osteoporosis?
Have you experienced more than one inch loss in height?
Have you taken Prednisone for the past 3 months?
Do you weigh less than 127 pounds?
Do you have a parent with prior hip fracture?
Please check the known treatments for Osteoporosis if they currently apply to you.
Weight bearing exercise for more than 20 minutes, 3 days a week
Calcium with Vitamin D 1200-1500 mg/day
Antacids containing Calcium such as Tums
Hormone Replacement Therapy
Fosamax
Actonel
Evista
Miacalcin nose spray
Boniva
Check the drugs that apply to you:
Check the diseases that apply to you:
Steroids
Hyperthyroidism
Tomoxifen
Hypothyroidism
Synthroid
Rhematoid arthritis
Thyroxine
Hyperparathyroidism
Phenytoin
CRI
Heparin
Colitis
Lithlum
Diabetes
Other
Cancer
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Parent category: Life