Osteoporosis Risk Factor Questionnaire

Name*
First Last
Date
Date Format: MM slash DD slash YYYY
Date of Birth*
Date Format: 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
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Atelvia*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Evista*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Forteo*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Fosamax*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Calcium*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Zometa*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Prolia*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Reclast*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
IV Boniva*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Boniva*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: MM slash DD slash YYYY
Vitamin D*
- Yes
- No
Date Started
Date Format: MM slash DD slash YYYY
Date Stopped
Date Format: 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

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Specialties/Services we offer

Joint injections
General rheumatology
Osteoporosis
Osteoarthritis (joint pain)
Inflammatory arthritis
(including rheumatoid, psoriatic, etc.)
Lupus
Lyme Disease
Vasculitis
Fibromyalgia
Complex Arthritis Problems

Specialties/Services we offer

Musculoskeletal Ultrasound
Viscosupplementation for knee arthritis
Clinical research trials
Bone density
Vertebral fracture analysis
Body composition analysis
(body fat, lean muscle mass)
X-rays
Infusions
Lab draws

Contact Information

Emkey Arthritis & Osteoporosis Clinic
and Osteoporosis Clinic, PC

1200 Broadcasting Road
Suite 200
Wyomissing, PA 19610

(office) 610-374-8133
(Billing) 855-326-7251
(fax) 610-375-1206
Email: contact@emkeyarthritis.com