Follow-up Form

Please verify your information.

Name: Date of Birth: Record Number: Location: In Office: Telehealth:

Telephone: Email:

Please indicate how you came upon our Bone Health Program and please indicate if/with whom you want us to share the results of this assessment.

Click/tap boxes for "yes." Leave them empty for "no."

Referral Source:

Name/Practice Phone Website/Email/Facebook Permission to share

Please indicate your current employment status, and the activity level used.

Click/tap boxes for "yes." Leave them empty for "no."

Please provide your recent Height/Weight and any recent changes, BMI (if you know it) and Hand Dominance.

Height (current) Height (prior) Weight Weight loss/gain BMI Hand Dominance

Please list all Medication and Food Allergies and any Food/Additive Intolerance.

Click/tap boxes for "yes." Leave them empty for "no."

Medication Allergies Which Medication(s)? Reaction / Comments

Food Allergies Which Food(s)? Reaction / Comments

Avoid Food/Additive Which Food/Additive(s)? Reaction / Comments

Do you consider yourself in good health?

Click/tap boxes for "yes." Leave them empty for "no."

Impression of Current Health Status – are you in good health? Additional Comments

Please indicate any family history for Osteoporosis or any other bone health related issues including genetic diseases affecting bone or muscle.

Click/tap boxes for "yes." Leave them empty for "no."

Family history of {{disorder}}: Mother Father Sibling Additional Info

Please indicate which medical providers that you are currently seeing for general medical care and for any current medical conditions.

Click/tap boxes for "yes." Leave them empty for "no."

{{specialty}}: Name: Reason:

Please indicate recent consultations and the purpose.

Click/tap boxes for "yes." Leave them empty for "no."

{{specialty}}: Date: Examination/Purpose: Comments:

Please indicate any recently performed diagnostic studies that you may have had within the past year.

Click/tap boxes for "yes." Leave them empty for "no."

{{study}}: Date: Examination/Purpose: Comments:

Please indicate whether or not you participate in any of the listed activities.

Click/tap boxes for "yes." Leave them empty for "no."

{{activity}}: Type of program / Hours a week participating

Have you fallen or have had any close-calls?

Click/tap boxes for "yes." Leave them empty for "no."

{{fall}}: # Times Circumstance Fracture Treatment

Have you ever fractured a bone?

Click/tap boxes for "yes." Leave them empty for "no."

Fracture #{{n}}: Fractured Bone Code: Age: Date: How did it happen?: How was it treated?:

Please list all current and past medications taken.

Click/tap boxes for "yes." Leave them empty for "no."

Medication #{{n}}: Currently taking? Medicine Name: Dose: Age: Start: Stop: Diagnosis:

Please list all current and vitamins and supplements taken.

Click/tap boxes for "yes." Leave them empty for "no."

Vitamin/Supplement #{{n}}: Currently taking? Vitamin/Supplement Name: Dose: Age: Start: Stop: Comments:

Please answer the following eating habits and general nutrition questions.

Click/tap boxes for "yes." Leave them empty for "no."

Do you read nutrition labels? Are food prices an issue?

Home cooked meals with fruits and vegetables? # Day # Week

Home meals that consist of processed / packaged foods? # Day # Week

Eat-out or bring home take-out meals? # Day # Week

Junk food consumption? # Day # Week

Do you practice any of the following diets?

Click/tap boxes for "yes." Leave them empty for "no."

{{diet}}: Age: Start: Stop: Reason/Comments:

Do you eat any of the following food types?

Click/tap boxes for "yes." Leave them empty for "no."

{{food}}: # Servings per day

PLEASE PROVIDE OUR OFFICE WITH ANY MEDICAL CHANGES INCLUDING MEDICATION UPDATES/FALLS/FRACTURES/SURGERIES AND ANY NEW MEDICAL DIAGNOSES SINCE YOUR LAST BONE HEALTH VISIT:

Additional Information:

Please provide updated DXA examinations, lab results, and x-ray reports performed since your last visit in our office via email: /follow-up-form.

Submit