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Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
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)?
*
