Coastal New Patient Encounter Form Page 4

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OSTEOPOROSIS
Since age 45, have you experienced a fracture (broken bone) at any of the following sites:
Hip
Rib
Wrist
Spine
None
Have you ever been treated for or told that you have osteoporosis or osteopenia?
Yes
No
Have you had a bone density test (DEXA) performed in the past two years?
Yes
No
If Yes: Where:
When:
Have you ever been diagnosed with menopause (change of life)?
Yes
No
ADDITIONAL INFO
Please share any additional info that you would like for your treating physician to know about:
Please bring the following items with you to your appointment:
• Photo ID Card (Drives License, etc.)
• Current Insurance Card(s)
• Please come prepared to pay any Co-Pay/Co-Insurance on the date of your visit.
Signature (Patient or Legal Guardian)
Date

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