"Fracture Risk Assessment Form - Prescott Osteoporosis Testing Center"

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PRESCOTT OSTEOPOROSIS TESTING CENTER
3633 Crossings Drive Prescott, AZ 86305 (
P) 928-445-2424 (F) 928-778-5561
FRACTURE RISK ASSESSMENT
Patient’s Last Name: ________________________ First Name: __________________________ M.I. _____
Returning Patients – Please provide your current address:
__________________________________________________________________________________________
Sex: Male or Female Date of Birth: ____\____\____ Referring Provider: ___________________________
Would you like your report to be sent to any other local providers? ________________________________
(Please circle the appropriate answers)
1. Have you ever fractured or broken a bone as an adult?
Yes
No
2. Have either of your parents fractured a hip?
Yes
No
3. Do you now, or have you ever smoked?
Yes
No
When did you start? _____________
If you have quit, when? ___________
**For calculation of your fracture risk, a history of smoking is considered the same as currently smoking.**
4. Do you now, or have you ever had chronic use of glucocorticoids?
Yes
No
(Long term use of prescribed steroids oral/inhaled)
5. Do you consume more than 3 alcoholic drinks per day?
Yes
No
6. Do you have any of the following conditions?
Rheumatoid arthritis:
Yes
No
Insulin dependent diabetes:
Yes
No
Hyperthyroidism (overactive):
Yes
No
Premature menopause:
Yes
No
(under age 45 – including surgical)
Chronic malnutrition:
Yes
No
Liver disease:
Yes
No
Low testosterone:
Yes
No
7. Are you CURRENTLY taking any of the following medications for treatment of osteoporosis?
______Calcium Amount ___________mg
______Vitamin D (separately from Multi) Amount? _________ IU
______ Alendronate
______Fosamax
______Forteo
______Actonel
______ Boniva
______ Evista
______ Prolia
______ Reclast / Zometa
-----------------------------------------------------
-----------------------------------------------------
OFFICE USE ONLY
Weight: ________________ Height: ________________ Peak Height: ________________
BMI: ______________ Major Osteoporotic: _____________ Hip Fx: _______________
PRESCOTT OSTEOPOROSIS TESTING CENTER
3633 Crossings Drive Prescott, AZ 86305 (
P) 928-445-2424 (F) 928-778-5561
FRACTURE RISK ASSESSMENT
Patient’s Last Name: ________________________ First Name: __________________________ M.I. _____
Returning Patients – Please provide your current address:
__________________________________________________________________________________________
Sex: Male or Female Date of Birth: ____\____\____ Referring Provider: ___________________________
Would you like your report to be sent to any other local providers? ________________________________
(Please circle the appropriate answers)
1. Have you ever fractured or broken a bone as an adult?
Yes
No
2. Have either of your parents fractured a hip?
Yes
No
3. Do you now, or have you ever smoked?
Yes
No
When did you start? _____________
If you have quit, when? ___________
**For calculation of your fracture risk, a history of smoking is considered the same as currently smoking.**
4. Do you now, or have you ever had chronic use of glucocorticoids?
Yes
No
(Long term use of prescribed steroids oral/inhaled)
5. Do you consume more than 3 alcoholic drinks per day?
Yes
No
6. Do you have any of the following conditions?
Rheumatoid arthritis:
Yes
No
Insulin dependent diabetes:
Yes
No
Hyperthyroidism (overactive):
Yes
No
Premature menopause:
Yes
No
(under age 45 – including surgical)
Chronic malnutrition:
Yes
No
Liver disease:
Yes
No
Low testosterone:
Yes
No
7. Are you CURRENTLY taking any of the following medications for treatment of osteoporosis?
______Calcium Amount ___________mg
______Vitamin D (separately from Multi) Amount? _________ IU
______ Alendronate
______Fosamax
______Forteo
______Actonel
______ Boniva
______ Evista
______ Prolia
______ Reclast / Zometa
-----------------------------------------------------
-----------------------------------------------------
OFFICE USE ONLY
Weight: ________________ Height: ________________ Peak Height: ________________
BMI: ______________ Major Osteoporotic: _____________ Hip Fx: _______________