Screening
Test
Disclaimer
Disclaimer
| 1. Have you had a previous "Bone Mineral Density (BMD)" test (DEXA scan) in which you were given the diagnosis of 'OSTEOPOROSIS"? | Yes No |
| 2.
If you have not been on estrogen daily,
or have only taken it intermittently since
the onset of menopause (or surgical removal
of the ovaries), check Y. If you have been on estrogen daily, check N. (Ignore question if N/A) |
Yes No |
| 3. Was there a delay between menopause (or surgical removal of the ovaries) and the onset of estrogen therapy? | Yes No |
| 4. Do you have a history of "vertebral" abnormalities/ disease? (i.e., scoliosis, kyphosis, fracture) | Yes No |
| 5. Have you ever consistently been on "steroid" therapy for greater than "3" months equivalent to >7.5mg of prednisone each day? | Yes No |
| 6. Do you have a diagnosis of hyperparathyroidism A condition due to an increase secretion of the parathyroids, causing elevated serum calcium, decreased serum phosphorus, and increased excretion of both calcium and phosphorus, calcium stones and sometimes generalized osteitis fibrosa cystica.? | Yes No |
| 7.
Do you have a diagnosis of Osteopenia
1. Decreased calcification or density
of bone; a descriptive term applicable
to all skeletal systems in which such
a condition is noted; carries no implication
about causality. 2. Reduced bone mass due to inadequate osteoid synthesis.or Osteomalacia ? A disease characterized by a gradual softening and bending of the bones with varying severity of pain; softening occurs because the bones contain osteoid tissue that has failed to calcify because of lack of vitamin D or renal tubular dysfunction; more common in women than in men, osteomalacia often begins during pregnancy. Syn: rachitis tarda, adult rickets, late rickets. |
Yes No |
| 8. Do you have a diagnosis of Endometriosis ? Ectopic occurrence of endometrial tissue, frequently forming cysts containing altered blood. Syn: endometrial implants. | Yes No |
| 9. Do you have a diagnosis of Rheumatoid Arthritis ? a generalized disease, occurring more often in women, which primarily affects connective tissue; arthritis is the dominant clinical manifestation, involving many joints, especially those of the hands and feet, accompanied by thickening of articular soft tissue, with extension of synovial tissue over articular cartilages, which become eroded; the course is variable but often is chronic and progressive, leading to deformities and disability. | Yes No |
| 10.
Do you have a diagnosis of Lymphoma
Any neoplasm of lymphoid tissue; in general
use, synonymous with malignant lymphoma.,
Leukemia
Progressive proliferation of abnormal
leukocytes found in hemopoietic tissues,
other organs, and usually in the blood
in increased numbers. Leukemia is classified
by the dominant cell type, and by duration
from onset to death. This occurs in acute
leukemia within a few months in most cases,
and is associated with acute symptoms
including severe anemia, hemorrhages,
and slight enlargement of lymph nodes
or the spleen. The duration of chronic
leukemia exceeds one year, with a gradual
onset of symptoms of anemia or marked
enlargement of spleen, liver, or lymph
nodes., Multiple Myeloma ...an uncommon disease that occurs more frequently in men than in women and is associated with anemia, hemorrhage, recurrent infections, and weakness. Ordinarily, it is regarded as a malignant neoplasm that originates in bone marrow and involves chiefly the skeleton, with clinical features attributable to the sites of involvement and to abnormalities in formation of plasma protein; characterized by numerous diffuse foci or nodular accumulations of abnormal or malignant plasma cells in the marrow of various bones (especially the skull), causing palpable swellings of the bones, and occasionally in extraskeletal sites; radiologically, the bone lesions have a characteristic punched-out appearance. or Thalessemia Any of a group of inherited disorders of hemoglobin metabolism in which there is impaired synthesis of one or more of the polypeptide chains of globin; several genetic types exist, and the corresponding clinical picture may vary from barely detectable hematologic abnormality to severe and fatal anemia. |
Yes No |
| 11. Do you have a diagnosis of Hyperthyroidism ? An abnormality of the thyroid gland in which secretion of thyroid hormone is usually increased and is no longer under regulatory control of hypothalamic-pituitary centers; characterized by a hypermetabolic state, usually with weight loss, tremulousness, elevated plasma levels of thyroxin and/or triiodothyronine, and sometimes exophthalmos; may progress to severe weakness, wasting, hyperpyrexia, and other manifestations of thyroid storm; often associated with exophthalmos (Graves disease). | Yes No |
| 12. Do you take "Dilantin", "Tegretol", "Phenobarbital" or "Lithium"? | Yes No |
|
13.
Do you take any kind of "steroid"
medication regularly? |
Yes No |
| 14. Do you take (or have taken) insulin? | Yes No |
| 15.
Are you a transplant patient taking immuno-suppressant
drugs? (e.g., cyclosporin, azathioprine) |
Yes No |
| 16.
Do you have kidney problems? (renal insufficiency, renal failure, renal tubular disorders) |
Yes No |
| 17. Did you have menopause before age 48? | Yes No |
| 18.
Have you had a hip fracture?
If you DID NOT check any "YES" boxes you should be aware that there are other risk factors not listed on this questionnaire that may put you at risk for Osteoporosis. You should see your doctor for a complete evaluation.
|
Yes No |
| 18. Have you had a rib fracture? | Yes No |
| 19. Have you had a pelvic fracture | Yes No |
| 20. Have you had a fracture of lower forearm or wrist. | Yes No |
©
1999 Osteoporosis Prevention Center
2800 3rd Ave., San Diego, CA 902103-6204
(619) 291-2321
2800 3rd Ave., San Diego, CA 902103-6204
(619) 291-2321