NAME 
AGE SEX
HAVE YOU HAD THIS TEST BEFORE? YES( ) NO ( )
WHERE WHEN
DATE OF LAST MENSTRUAL PERIOD:
| ARE YOU OR COULD YOU BE PREGNANT? YES ( ) NO ( ) |
|
PLEASE LIST ALL FRACTURES AND AGE AT WHICH THEY OCCURRED
PLEASE LIST ALL MEDICATIONS (including vitamins, supplements, etc.)
HAVE YOU A HISTORY OF (please check all that apply)
Severe menstrual irregularity when younger
Eating disorder (anorexia)
Hyperthyroidism (over active thyroid)
Hyperparathyroidism
Diabetes (age at onset)
Adrenal gland disease (Cushing's or Addison's disease)
Epilepsy
Kidney disease
Liver disease
Gastro-intestinal disease with severe diarrhea, malabsorption, etc.
Cigarette smoking (how many packs per year) (how many years)
Do you drink alcoholic beverages (how often and how much)
Other serious illness (please specify)
DO YOU TAKE OR HAVE YOU TAKEN FOR A LONG PERIOD (please check all that apply)
Synthroid or other thyroid medication
Cortisone
Dilantin
Lupron
Heparin
