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)
Other – please specify ____________________ 13. Do you have any of the following medical conditions? Anorexia of Bulimia
Any Seizure Disorders
Asthma or Emphysema
End stage renal disease
Inflammatory bowel diseases
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)?
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Mitchell, Jennifer L. Most Effecitve Lawyers: Class Action Ruling allows non-FDA-approved uses of drug Neil Kodsi, Carlton Fields; Miriam Harmatz, Florida Legal Services; Shawn Boehringer, Legal Aid Service of Broward Medicaid recipients across the nation won a victory when Florida’s Agency for Health Care Administration dropped its appeal in a federal class action case on c