Colorado Heart & Body Imaging

Bone Densitometry (QCT)

Patient History

Name:______________________________________________________________________

Birthdate:__________________Age:______Height:__________Weight:_______ M / F

Reason Doctor Ordered Test:______________________________________________________

Previous QCT Test With Us?: ð YES ð NO

If so, When?___________________________________________________________________

Results of Previous Test:_________________________________________________________

Prior History of Low Impact Fracture? ð YES ð NO

If Yes, Which Bone?____________________________________________________________

Family History of Low Impact Fracture? ð YES ð NO

If Yes, Family Relationship:_______________________________________________________

Have You Ever Fractured any Bone? ð YES ð NO

If Yes, Which Bones at What Age?_________________________________________________

Do You Exercise Regularly? ð YES ð NO

How Many Times A Week?________________How Long?_____________________________

Do You Take Calcium Supplements? ð YES ð NO

How Many mg per Day?_________________________________________________________

Do You Take Vitamin D Supplements? ð YES ð NO

How Many mg per Day?_________________________________________________________

Do You Now, Or Did You Ever Smoke? ð YES ð NO

If Yes, For How Many Years?___________________Packs per Day:______________________

When Did You Quit?____________________________________________________________

How Many Alcoholic Beverages Do You ConsumeWeekly?_____________________________

QCT Questionnaire Continued.

Medical History

Have You Been Through Menopause? ð YES ð NO

At What Age?_________________________________________________________________

Have You Had a Hysterectomy or Ovaries Removed? ð YES ð NO

At What Age?_________________________________________________________________

Are You Taking Estrogen Replacements? ð YES ð NO

For How Many Years?__________________________________________________________

Have You Ever Had Cancer? ð YES ð NO

If Yes, What Kind?_____________________________________________________________

How Was It Treated?___________________________________________________________

Have you ever had:

Hypothyroidism? ð YES ð NO

Hyperparathyroidism? ð YES ð NO

Cushing Disease? ð YES ð NO

Have You Ever Had Surgery To Your Small Or Large Intestine? ð YES ð NO

If Yes, What Area and When?_____________________________________________________

Medications	Why Taken?	# Years Taken	Daily Dosage
Prednisone/Cortisone
Tamoxifen (Novadex)
Raloxifene (Evista)
Alendronate (Fosamax)
Etidronate (Didronel)
Calcitonin (Calcimar)
Anticonvulsants (Dilantin)
Thyroid (Synthroid)

Please List Any Medications You May Be Taking: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________