New Patient Form

Please select any and all options that apply to you. If something doesn't apply to you, leave it empty. Only some parts of this form will apply to you, feel free to ignore the rest.

(0) CCOA Bone Health Questionnaire

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

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

(1) Please provide your telephone and Email.

Telephone: Email:

(2) Please indicate your residence/age/demographics.

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

Were you born in the United States? Country of Birth: Years in US: Home City/State:

(3) 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.

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Referral Source:

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

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

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

(5) Please check the responses that apply. These topics will be detailed in other parts of the questionnaire. Additional information and comments can be made in later sections.

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(6) 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

(7) 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

(8 & 45) 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

(9 & 45) Do you have any other ongoing significant health concerns?

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Are there any other ongoing significant health concerns? Additional Information

(10) Please indicate current and past Tobacco/Alcohol/Drug use and also current and past Coffee/Energy Drink/Soda consumption.

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

{{smoke}}: # Packs Years Smoking Years Quit Attempted to Quit

{{alcohol}}: # Drinks/day # Drinks/year Years Quit Attempted to Quit

{{drug}}: Drug(s) used: Years used: (placeholder) Attempted to Quit

(11) 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

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

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{{specialty}}: Name: Reason:

(13) Please indicate recent consultations and the purpose.

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

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

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

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

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

(16) FEMALES ONLY: Please indicate if any of the listed conditions are in your medical history.

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{{historyAndCode[0]}} Code Age: Date Dx: Comments/Treatment:

(16) MALES ONLY: Please indicate if any of the listed conditions are in your medical history.

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

{{historyAndCode[0]}} Code Age: Date Dx: Comments/Treatment:

(17) Please indicate if any of the listed conditions are in your medical history.

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{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(18) Please indicate if any of the listed conditions are in your medical history.

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{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(19) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(20) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(21) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(22) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(23) Please indicate if any of the listed conditions are in your medical history.

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{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(24) Please indicate if any of the listed conditions are in your medical history.

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{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(25) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(26) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(27) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(28) Please indicate if any of the listed conditions are in your medical history.

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{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(29) Please indicate if any of the listed conditions are in your medical history.

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

{{condition[0]}} Code Age: Date Dx: Comments/Treatment:

(30) Have you fallen or have had any close-calls?

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

{{fall}}: # Times Circumstance Fracture Treatment

(31) Please indicate if any of the listed conditions are in your medical history.

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{{condition}} Spine UE LE Areas involved/Comments

(32) 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?:

(33) Please indicate if you had a surgical procedure performed – several specific surgeries are separately listed in the next three questions.

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

Major Surgery #{{n}}: Procedure: Age: Date: Reason: Complications:

(a) Any recent or past bariatric surgeries (weight-loss surgery)?

{{surgery}}: Age: Date: Results: Complications:

(b) Any recent or past endocrine surgeries?

{{surgery}}: Age: Date: Results: Complications:

(c) Any recent or past major Orthopedic/Neurosurgeries?

{{surgery}}: Age: Date: Results: Complications:

(34) Do you have any other significant medical conditions not previously listed and please indicate if any of the listed conditions are in your medical history?

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

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Bone Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Cardiac/Vascular Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Pulmonary Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Endocrine Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

GI Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Obstetric-Gynecological Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Ophthalmologic Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Auditory Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Neurological Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Skin Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Psychiatric Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Poor Health Habits:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Infectious Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Kidney Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Liver Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Rheumatological Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Autoimmune Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Allergic Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Hematologic Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Cancerous Conditions:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

Organ Transplant:

{{condition[0]}}: Code Age: Date Dx: Treatment: Comments:

(35) Please list any medications that were prescribed for osteoporosis management (or for menopause).

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

Antiresorptive:

{{medicine}}: Dose: Age: Start: Stop: Comments:

Anabolic:

{{medicine}}: Dose: Age: Start: Stop: Comments:

SERMS:

{{medicine}}: Dose: Age: Start: Stop: Comments:

Hormone Replacement:

{{medicine}}: Dose: Age: Start: Stop: Comments:

Other

{{medicine}}: Dose: Age: Start: Stop: Comments:

(36) Have you taken any of the following medications or types of medications?

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

{{medicine}}: Dose: Age: Start: Stop: Diagnosis:

(37) Please list all current and past medications taken.

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

(38) 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:

(39) Are you taking, or have you ever taken supplemental Strontium? Have you taken supplemental Fluoride other than for tooth care?

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

{{supplement}}: Dose: Age: Start: Stop: Comments:

(40) 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

(41) Do you practice any of the following diets?

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

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

(42) Do you avoid any types of Foods/Additives for Medical/Personal/Religious Reasons?

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

Food/Additive #{{n}}: Food/Additive Name: Age: Start: Stop: Reason/Comments:

(43) Do you eat any of the following food types?

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

{{food}}: # Servings per day

(44) Have you ever used a Calcium Calculator?

Milk (8 oz.) servings per day Yogurt (6 oz.) servings per day Cheese (1 oz. or 1 cube) servings per day Soy/Almond Milk (fortified, 1 cup) servings per day Orange Juice (fortified, 8 oz) servings per day Calcium Estimate:

(45) Space for additional information.

Additional information:

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