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