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Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Dexa History
"
*
" indicates required fields
Name (last, first)
*
Date of Birth:
*
MM slash DD slash YYYY
Gender:
*
Male
Female
Date of Service:
*
MM slash DD slash YYYY
Ethnicity:
*
Menopause age:
*
Height:
*
Weight:
*
1) Have you had a previous hip/spine fracture or surgery?
*
Yes
No
2) Have you had any fractures during your adult life, which did not result from significant trauma (e.g., auto accident)?
*
Yes
No
3) Did either of your parents ever have a hip fracture?
*
Yes
No
4) Do you smoke?
*
Yes
No
5) Have you ever taken glucocorticoids?
*
Yes
No
6) Do you have rheumatoid arthritis?
*
Yes
No
7) Do you have secondary osteoporosis?
*
Yes
No
8) Are you being treated for osteoporosis?
*
Yes
No
9) Do you drink 3 or more alcoholic drinks per day?
*
Yes
No
10) Have you ever taken any of the following medications?
Select appropriate medication:
Actonel (risedronate)
Evista (raloxifene
Fosamax (alendronate)
Miacalcin (calcitonin)
Reclast (zoledronate)
Vitamin D
Boniva (ibandronate)
Forteo (parathyroid hormone)
HRT (estrogen/hormone therapy) Protelos (strontium ranelate)
Prolia (denosumab)
Calcium
None
11) Do you have any of the following medical conditions?
Select appropriate condition:
Anorexia/Bulimia
Asthma/Emphysema
End Stage Renal Disease
Hyperparathyroidism
Seizure Disorder
Cancer
Inflammatory Bowel Disease
Hysterectomy
Other
None
Other Conditions- Please specify
12) What was your max height?
*
13) Do you perform weight bearing exercise regularly?
*
Yes
No
14) Do you regularly consume dairy products?
*
Yes
No
15) Do you drink caffeinated beverages?
*
Yes
No
Female Only:
What age did your period start?
*
Are you premenopausal?
*
Yes
No
How many full-term pregnancies have you had?
*
Have you ever missed your period for more than 6 months in a row (not including menopause/pregnancy)?
*