Osteoporosis Risk Factor Questionnaire Name* First Last HiddenDate MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY Please forward a copy of my DEXA/VFA to the following physicians:Please indicate if you have ever had any of the following medical problems: Thyroid/Parathyroid Problems Asthma Diabetes Rheumatoid Arthritis Gastrointestinal Problems Back Pain Kidney Problems / Kidney Stones Cancer Please Answer The Following "Yes" or "No" Questions:Do you have a family history of osteoporosis?* Yes No Have you ever smoked?* Yes No For How Many Years Do you drink alcoholic beverages?* Yes No Have you lost height?* Yes No Have you ever used steroids (such as PREDNISONE) to treat chronic illness?* Yes No Have you ever fractured a bone?* Yes No Would you want to be notified of clinical trials for osteoporosis?* Yes No Do you currently or have you previously taken any of the following medications for bone health?Actonel* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Atelvia* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Evista* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Forteo* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Fosamax* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Calcium* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Zometa* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Prolia* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Reclast* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY IV Boniva* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Boniva* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY Vitamin D* Yes No Date Started MM slash DD slash YYYY Date Stopped MM slash DD slash YYYY If you have stopped taking one of these medications, please write the reason for stopping below: The following section is for female patients only:Have you been through menopause? Yes No At what age? Have you had a hysterectomy? Yes No Are you currently or have you taken hormones in the past? Yes No