Please print this page, complete it, and take it to your appointment.

Name:__________________________  Referring Physician:______________________ Age:_______________

Birthdate:___________ Past Height:_____________ Current Height:__________  Current Weight:________

Have you ever had a bone density scan? Y N (If so, when?)___________________

Have you ever had hip or spine surgery? Y N

Do you smoke? Y N         Do you exercise regularly? Y N

Have you ever had any of the following:

___ X-rays suggesting thinning of the bones            ___ Menopause

___ Prolonged absence of menstrual periods         ___ Hysterectomy

___ Use of danocrine to treat endometriosis           ___ Testosterone deficiency

___ Diagnosis of osteoporosis                                    ___ Rheumatoid Arthritis

___ Fractures associated with minimal trauma       ___ > 2 inch loss of height

___ Long-term use of steroids (ie. Prednisone)         ___ Hyperthyroidism

___ Abnormalities of parathyroid hormone             ___ Breast Cancer

___ Prostate Cancer

Current Medications:__________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you taking any of the following:

___ Estrogen Replacement Therapy                         ___ Calcium supplements

___ Vitamin D                                                                ___ Fosamax

___ Calcitonin                                                              ___ Other bone strengthening drugs