Bone Density Questionnaire | Bone & Body Blueprint Ltd

info@boneandbodyblueprint.co.nz0800 258 377

BODY COMPOSITION

BONE HEALTH TEST

BONE DENSITY BODY COMPOSITION DVA (DIGITAL VERTEBRAL ASSESSMENT)

LOCATION ABOUT US FREQUENTLY ASKED QUESTIONS PRICE LIST

Bone Densitometry Questionnaire

Please complete this form if you are booked for a Bone Density Scan.

Name

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Email

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Phone

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Postal Address

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Date of Birth

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Gender

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NHI Number

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Have you ever broken/fractured a bone as an adult?

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If yes, which bone/s and when (year)?

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If yes, was it in a fall?

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Have either of your parents had a hip fracture?

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Family history of Osteoporosis?

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Have you had any operations on your bones/joints?

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Have you had a recent X-Ray, CT or Nuclear Medicine Scan?

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Do you smoke?

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Tick any conditions that you have below:

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Overactive Thyroid

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On Thyroxine

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Overactive Parathyroid

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Long Term Kidney Disease

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Long Term Liver Disease

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Long Term Cortisone Therapy

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Rheumatoid Arthritis

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Osteoarthritis

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Osteogenesis Imperfecta

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Bowel Disease (Crohn's, Coeliac etc)

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Diabetes NIDDM or IDDM

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Tick any current therapies you have for your bone health:

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Calcium

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Vitamin D

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Hormone Replacements (Estraderm, Evista, Kilogest, Ogen, Primolut, Provera etc)

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Prolia (Denusomab)

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Forteo (Parathyroid Hormone)

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History of Protos treatment (Stontium Ranelate)

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History of Cancer treatments

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Have any of the above therapy/s started in the last year?

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If you have a history of Cancer treatments, which treatments?

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Have you had a Bone Density Scan previously?

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If yes, when and where?

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Date of last period (if applicable):

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Age of menopause (if applicable):

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Address

Message Sent.

Find Us

Inside Health on Mahoe
160 Mahoe Street, Te Awamutu
New Zealand 3800

0800 BLUEPRINT
(0800 258 377)

info@boneandbodyblueprint.co.nz

Bone Densitometry Questionnaire

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Name

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Phone

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Email

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Message

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BODY COMPOSITION

BONE HEALTH TEST

BONE DENSITY BODY COMPOSITION DVA (DIGITAL VERTEBRAL ASSESSMENT)

LOCATION ABOUT US FREQUENTLY ASKED QUESTIONS PRICE LIST