Professional Terrace Radiology Bone Densitometry Questionnaire
Patient: Please fill out this questionnaire at home before the bone density exam. Please do not wear metal belts, buttons, or zippers to the appointment. Allow 30 minutes for the exam. Do not take a calcium pill the day of your test. Please print out and bring the completed form to your appointment.

*To be completed by your physician/physician's office.

*Appointment Date: *Time:
*Ordered by: *Copies to:
Height: Weight:
Patient: DOB:
Phone: Area Code #

Check any answers that apply to you:

Women:
Any possibility of pregnancy?
Ovaries have been removed?
Going through menopause?
Past menopause?

Both Men and Women:
Do you smoke ?
Drink Milk? How many dairy serving per day?
Exercise? How many times per week?
Do you fall?

Medications: Dosage: Duration:
Estrogen, Hormone Replacement
Evista (Raloxifene)
Calcium Supplements or TUMS
Multivitamins or Vitamin D
Miacalcin (Calcitonin)
Fosamax (Alendronate)
Actonel (Risidronate)
Forteo
Testosterone
Other Osteoporosis Medications

PREVIOUS BONE DENSITY SCAN?
When? Where?

*To be completed by your physician/physician's office.

*Scan site:
2-Site (AP spine and Hip sites are standard if age < 65)
1-Site (Hip is standard if spine is non-interpretable, forearm is alternative site)

Please select at least one of the following or indicate another appropriate and billable diagnosis:

*Endocrine problems:
Oopherectomy
Menopausal symptoms: hot flashes insomnia menorrhagia
Post menopause
Estrogen deficiency
Testicular hypofunction
Hyperthyroidism
Hyperparathyroidism

*Mechanical problems:
Kyphosis
Loss of height
Vertebral compression fracture(s)
Stress Fracture (location):

*Metabolic problems:
Osteopenia, previously documented
Osteoporosis, previously documented
Chronic renal failure
Poly-cystic kidney disease
Celiac disease
Ulcerative colitis
Regional enteritis (Crohn's Disease)
Protein - calorie malnutrition
Anti-convulsant use: drug, dose, duration:
Steriod use (greater than or equal to equivalent of 7.5mg Prednisone/day x 3mo)
Other diagnosis

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