Advanced Osteoporosis  Screening

National Osteoporosis Foundation Professional Partner Network Member

2300 Genoa Business Park Drive, Suite 120, Brighton, MI, 48116 (810) 229-8550 

Laith A. Farjo, M.D.                                                                                                  Edward G. Loniewski, DO

General Orthopedic Surgery                                                                                       General Orthopedic Surgery

Sports Medicine                                                                                                           Joint Replacement

Shoulder Surgery                                                                                                          Osteoporosis Screening/Treatment

                                                                                                                                       ISCD Certified

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Osteoporosis Patient History Form

Please answer the following questions to help us in the treatment of your bones.  If you are not sure how to answer a question, leave the space blank and we will assist you with your answer.  All answers will of course be kept in strict confidence and treated as medical record information.

Name:__________________________________________________________________

 

Age: _______________         Height: __________               Weight: __________

 

Race:   ___ African American             ___Asian         ___ Caucasian             ___Hispanic

            ___ Native American              ___Other: ________________________________

Sex:     ___Female      ___Male

 

Referring Physician (if any): ________________________________________________

Important Questions About Your Health:

Have you fractured any bones during your adult life?             ___Yes            ___No

Does your family have a history of osteoporosis?                               ___Yes            ___No

Do you smoke more than half a pack of cigarettes per day?                ___Yes            ___No

Have you smoked in the past?                                                 ___Yes            ___No

How many servings of dairy products do you have every day? 

( one serving = 8 oz milk, 1.5 oz. Cheese, 8 oz. Yogurt,8 oz,

 cottage cheese or 4 oz of ice cream)                                                  Number: __________

Have you consumed three or more dairy servings per day

Throughout most of your life?                                                 ___Yes            ___No

Do you take calcium supplements daily?                                             ___Yes            ___No

            If so, how much?

            ___O-500mg/day        ___501-1000 mg/day              ___>1000mg/day

Do you exercise at least three times per week                        ___Yes            ___No

If yes, what type of exercise:

___ Aerobic dance      ___  Walking               ___Weight lifting        ___  Jogging 

 

other:  _______________________________________________________________

 

Do you drink more than two alcoholic beverages per day?                 ___Yes            ___No

 

 

Have you taken any of the following medications or treatments

Have you had any of the following conditions?

Do you have any general comments or questions about your health? _________________

 

 

-------------------------Remaining Questions for Women Only------------------------

Have you gone through menopause                                                      ___Yes            ___No

Did your menopause occur before age 45?                                         ___Yes            ___No

Have your ever had amenorrhea

(missed periods or never started periods)?                                         ___Yes            ___No

Have you ever taken hormones (not including birth control pills)?     ___Yes            ___No

Have you ever had any of the following side effects from hormones?

Have you ever been treated for osteoporosis or weak bones?            ___Yes            ___No

Have you had any of the following conditions?