Name: ______________________ Date:______________ DOB: _____________ Weight: ____________ Height: _______________ Ancestry: AFRICAN-AMERICAN CAUCASIAN HISPANIC OTHER      Thank You! Have you ever had a DXA Scan? YES NO   if so, where and when __________________________________ YES NO Have either one of your parents suffered a Hip Fracture?   Have you in your adult life ever suffered a Hip or Wrist YES NO   fracture from a minor fall/injury? Have you ever suffered a Vertebral Compression Fracture? YES NO   Have you had Hip replacement or lower back surgery? YES NO   Have you ever been diagnosed with any of the following? Type 1 Diabetes, Hyperthyroidism, Chronic Liver Disease, YES NO   Hypogonadism, Malnutrition/Malabsorption Has a Doctor or Nurse ever diagnosed you with YES NO   Rheumatoid Arthritis (RA) ? Have you Glucocorticoids (steroids) by mouth for longer YES NO   than 3 months? (ex. Prednisone) Are you a current Tobacco smoker? YES NO   Do you consume 3 or more alcoholic drinks a day? YES NO   Female Patients Continue Have you gone through YES NO If so, at what age? ________   Menopause?
Name: ______________________ Date:______________ DOB: _____________ Weight: ____________ Height: _______________ Ancestry:   AFRICAN-AMERICAN  CAUCASIAN  HISPANIC  OTHER Have you ever had a DXA Scan?  YES  NO if so, where and when __________________________________ Have either one of your parents suffered a Hip Fracture?  YES  NO Have you in your adult life ever suffered a Hip or Wrist fracture from a minor fall/injury?  YES  NO Have you ever suffered a Vertebral Compression Fracture?  YES  NO Have you had Hip replacement or lower back surgery?  YES  NO Have you ever been diagnosed with any of the following? Type 1 Diabetes, Hyperthyroidism, Chronic Liver Disease, Hypogonadism, Malnutrition/Malabsorption  YES  NO Has a Doctor or Nurse ever diagnosed you with Rheumatoid Arthritis (RA) ?  YES  NO Have you Glucocorticoids (steroids) by mouth for longer than 3 months? (ex. Prednisone)  YES  NO Are you a current Tobacco smoker?  YES  NO Do you consume 3 or more alcoholic drinks a day?  YES  NO Female Patients Continue Have you gone through Menopause?  YES  NO If so, at what age? ________ Thank You!
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