East Lansing Orthopedic Association
Male Osteoporosis Risk Test
________________________________________________________________________________________
Have you had a bone mineral density test in the last year, or do
you get a bone density test regularly through another physician?
Yes
No
Don't Know
________________________________________________________________________________________
Today's Date
First Name
Middle Initial
Patient's Legal Last Name
Birth date
Home
Work
Cell
Best Contact Number
________________________________________________________________________________________
Have you had a height loss since age 40?
Yes
No
Don't Know
Have either of your parents been diagnosed with
osteoporosis or a broken bone after a minimal fall?
Yes
No
Don't Know
Do you fall often?
Yes
No
Have you suffered a fracture from a minimal fall as an adult?
Yes
No
Are you lactose intolerant or have a low dairy intake?
Yes
No
Do you take calcium supplement?
Yes
No
Have you been diagnosed with vitamin D deficiency?
Yes
No
Do you smoke?
Yes
No
Do you exercise less than 2 times per week?
Yes
No
Yes
No
Have you ever taken steroid medications for more than 3 months?
Yes
No
Do you have prostate problems?
Have you had hip surgery?
Yes
No
Have you had back surgery?
Yes
No
________________________________________________________________________________________
Do you have any of the following? If
you don't know for sure, answer no.
Cushing's Syndrome
Yes
No
Thyroid Disease
Yes
No
Crohn's Disease
Yes
No
Paget's Disease
Yes
No
Ulcerative Colitis
Yes
No
Rheumatoid Arthritis
Yes
No
Lupus
Yes
No
Diabetic (insulin dependent)
Yes
No
Celiac Disease
Yes
No
Parathyroid Disease
Yes
No
