DEXA Scan Questionnaire

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Yes
No
Have you had any fractures during your adult life which did not result from significant trauma (e.g., auto accident)?
Have you had a previous hip or vertebral fracture?
Did either of your parents ever have a hip fracture?
Do you smoke?
Have you taken Glucocorticoids (steroids) for more than three months consecutively?
Do you have rheumatoid arthritis?
Have you been diagnosed with secondary osteoporosis by your physician? (Osteoporosis from anything other than age or menopause)
Do you drink 3 or more alcoholic drinks per day?
Are you being treated for osteoporosis?
Have you had a previous hip or vertebral fracture unrelated to trauma? (auto accident, fall from height, etc.)
Do you perform weight bearing exercise regularly?
Do you regularly consume dairy products?
Do you drink caffeinated beverages?

Do you have any of the following medical conditions? (check all that apply)

Anorexia or Bulimia
Asthma or Emphysema
End stage renal disease
Hyperparathyroidism
Any Seizure Disorders
Cancer
Inflammatory Bowel Diseases
Hysterectomy
Other

Have you ever taken any of the following medications? (check all that apply)

Actonel (risedronate)
Boniva (ibandronate)
Calcium
Evista (raloxifne)
Forteo (parathyroid hormone)
Fosamax (alendronate)
HRT (estrogen/hormone therapy)
Miacalcin (calcitonin)
Prolia (Denosumab)
Protelos (strontium ranelate)
Reclast (zoledronate)
Vitamin D
Other


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