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Imagecare, llc

ImageCare, LLC
710 Rabon Road * Columbia, SC 29203
Phone: (803) 462-3680
Patient History Questionnaire

Name: _________________________ Today’s Date: ___________________________
Patient ID: _____________________ Sex: ___________________________________
Current Height: _________________ Date of Birth: ___________________________
Weight: ________________________ Referring Physician: _____________________
Menopause Age: _________________Ethnicity: _______________________________
1. Have you had a previous hip or vertebral fracture?

Yes No
2. Have you had any fractures during your adult life which
Yes No
did not result from significant trauma (e.g., auto accident)?
3. Did either of your parents ever have a hip fracture?

Yes No
4. Do you smoke?
Yes No
5. Have you ever take Glucocorticoids?
Yes No
6. Do you have rheumatoid arthritis?
Yes No
7. Do you have secondary osteoporosis?
Yes No
8. Do you drink 3 or more alcoholic drinks per day?
Yes No
9. Are you being treated for osteoporosis?
Yes No
10. Have you ever had back surgery?
Yes No
11. Have you ever had hip surgery?
Yes No

12. Have you ever taken any of the following medications?
Actonel (ie. risedronate)
Boniva (i.e. ibandronate)
Evista (i.e. raloxifene)
Forteco (i.e. parathyroid hormone)
Fosamax (i.e. alendronate)
HRT (i.e. estrogen/hormone therapy)
Miacalcin (i.e. calcitonin)
Protelos (i.e. strontium ranelate)
Reclast (i.e. zoledronate)
Prolia (i.e. denosumab)
Vitamin D
Calcium
Other – please specify ____________________
13. Do you have any of the following medical conditions?
Anorexia of Bulimia
Any Seizure Disorders
Asthma or Emphysema
Cancer
End stage renal disease
Inflammatory bowel diseases
Hyperparathyroidism
Hysterectomy
Other – please specify _____________________

14. What was your maximum height (inches)? ___________
15. Do you perform weight bearing exercises regularly?

Yes No
16. Do you regularly consume dairy products?
Yes No
17. Do you drink caffeinated beverages?
Yes No

If Female:
18. At what age did you period start? ______
19. Are you pre-menopausal?

Yes No
20. How many full term pregnancies have you had?
___________
21. Have you ever missed your period for more than 6 months Yes No
In a row (not including pregnancy or menopause)?

Source: http://imagecarellc.com/wordpress/wp-content/uploads/2013/12/dexa-questionnaire.pdf

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