Osteoporosis Evaluation

Please fill this evaluation out to the best of your ability.The provider will be going over this in detail
with you during your office visit.

Patient Name:

DOB(MM-DD-YYYY):

FOR FEMALE PATIENTS ONLY:
Age at which menstruation began:
If applicable, age at which menopause occurred:
Did menopause occur due to surgery? YesNo
If yes, what was the indication/reason for surgery?
Number of biological children:

FOR MALE PATIENTS ONLY:
Have you even been diagnosed with a low testosterone level? YesNo
Have you experienced decreased libido or sexual dysfunction? YesNo
Have you ever been diagnosed with prostate cancer? YesNo

FOR ALL PATIENTS:
1. Have you ever used any of the following medications? Check all that apply
STEROIDSBLOOD THINNERSMETHOTREXATECYCLOSPORINE

2. Have you ever been diagnosed with: Check all that apply
PITUITARY PROBLEMSOVERACTIVE THYROIDRHEUMATOID ARTHRITIS

3. Have you ever had a Bone Density Scan (DEXA)? YesNo
If yes, when? (date). Where?

4. Have you had any fractures? YesNo
If yes, Please list them below indicating site on body, approximate year and how it happened:

5. Have you ever had treatments for low bone density? YesNo

5. Have you ever had treatments for low bone density?
YesNo

6. Do you take calcium tablets? YesNoIf yes, what kind and how many?

7. Do you take vitamin D? YesNo
If yes, what dose?

8. What other medications do you take specifically for osteoporosis?

9. How long have you been taking the medication listed in Question 8?

10. Do any of your family members have a history of osteoporosis? YesNo
If yes, who?

Thank you for taking the time to complete our health history forms!