University Radiology | NJ Imaging Center & Diagnostic Radiology

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Sex (Other) Details:

Sex recorded at birth on your original birth certificate:

Sex on Birth Certificate (Other) Details:

Please select the ethnicity that best describes you:

Prior lower spine or hip surgery?

Cement (Vertebroplasty / Kyphoplasty) in lower spine?

Do you have hyperparathyroidism?

Are you left-handed or right-handed?

Are you (select one)?

Pre-menopausal (I usually have regular menstrual periods)

Peri-menopausal (Irregular periods, but I have had at least 1 period in the past 12 months)

Post-menopausal (I have NOT had a menstrual period for more than 12 months) or Hysterectomy

Is there any possibility that you are pregnant?

Yes No

Calcium (e.g. Tums, Citracal, Caltrate, Os-Cal)

Vitamin D (e.g. Calciferol, Caltrate, Citracal, Os-Cal, Calcium+D)

Alendronate (Fosamax/Fosamax+D)

Year Began:

Year Ended:

Risedronate (Actonel/Atelvia)

Year Began:

Year Ended:

Ibandronate (Boniva)

Year Began:

Year Ended:

Year Began:

Year Ended:

Year Began:

Year Ended:

Teriparatide (Forteo)

Year Began:

Year Ended:

Zoledronic Acid (Reclast/Aclasta/Zometa)

Year Began:

Year Ended:

Abaloparatide (Tymlos)

Year Began:

Year Ended:

Estrogen/Hormone Replacement Therapy (e.g. Duavee)

Year Began:

Year Ended:

Other Osteoporosis Medication Treatment

Medication:

Year Began:

Year Ended:

Do you drink 3 or more units of alcohol daily?

Hip fracture in your father or mother?

Currently or ever taken oral/IV steroids (e.g. prednisone / cortisol) for more than 3 months? (equivalent dose of prednisone 5mg or more daily) (topical / inhaled steroids are not applicable)

Have you suffered a wrist/hip/spine fracture in your adult life which occurred spontaneously or arising from low-impact trauma or fall from normal standing height?

Do you have any reason for secondary osteoporosis? (e.g. hyperparathyroidism, type I diabetes, cystic fibrosis, osteogenesis imperfecta, untreated long-standing hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition/malabsorption, chronic liver/kidney disease, multiple myeloma)

Have you been diagnosed with rheumatoid arthritis?

Do you currently smoke?

DEXA Questionnaire

Are you currently taking any of the following supplements (Select all that apply):

Are you currently, or have you ever taken the following medications?

FRAX Questionnaire