osteoporosis evaluation form – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

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:


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

Have you even been diagnosed with a low testosterone level?
Have you experienced decreased libido or sexual dysfunction?
Have you ever been diagnosed with prostate cancer?

1. Have you ever used any of the following medications? Check all that apply

2. Have you ever been diagnosed with: Check all that apply

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

4. Have you had any fractures?
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?

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

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

7. Do you take vitamin D?
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?
If yes, who?

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