Bone Density Questionnaire | Bone & Body Blueprint Ltd

Bone Densitometry Questionnaire

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

Name

Phone

Postal Address

Date of Birth

Gender

NHI Number

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

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

If yes, was it in a fall?

Have either of your parents had a hip fracture?

Family history of Osteoporosis?

Have you had any operations on your bones/joints?

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

Do you smoke?

Tick any conditions that you have below:

Overactive Thyroid

On Thyroxine

Overactive Parathyroid

Long Term Kidney Disease

Long Term Liver Disease

Long Term Cortisone Therapy

Rheumatoid Arthritis

Osteoarthritis

Osteogenesis Imperfecta

Bowel Disease (Crohn's, Coeliac etc)

Diabetes NIDDM or IDDM

Tick any current therapies you have for your bone health:

Calcium

Vitamin D

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

Prolia (Denusomab)

Forteo (Parathyroid Hormone)

History of Protos treatment (Stontium Ranelate)

History of Cancer treatments

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

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

Have you had a Bone Density Scan previously?

If yes, when and where?

Date of last period (if applicable):

Age of menopause (if applicable):

Address

Message Sent.

0800 BLUEPRINT
(0800 258 377)

info@boneandbodyblueprint.co.nz

Bone Densitometry Questionnaire

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Pukekohe 2120

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