BONE DENSITY QUESTIONNAIRE UPDATED 08.27.09

1 Mammography bone Densitometry Breast Ultrasounds bone DENSITY QUESTIONNAIRE Please answer the following questions. If you are unsure how to answer a question, please leave the space blank and a staff member will assist you. Answers are confidential medical record information and are important to assist in the correct interpretation of your bone DENSITY examination. Name_____ Height_____ Weight_____ Female_____ Male_____ Date of Birth_____ Age_____ Social Security #_____Referring Physician_____ Race (Necessary): African- American_____ Asian_____ Caucasian (White)_____ Hispanic_____ Other _____ ** ___Yes ___ No Is there a chance that you are pregnant?

2 ___Yes ___ No Have you had a barium X- ray in the last 2 weeks? ___Yes ___ No Have you had a nuclear medicine scan or injection of an X- ray dye in the last week? ___Yes ___ No Do you have hyperparathyroidism or a high calcium level in your blood? If you answered yes to any of the above, speak to our receptionist right away. ** MEDICAL HISTORY ___Yes ___ No Have you ever had a bone DENSITY (DEXA) Scan before? When? _____ Where?

3 _____ Results? _____ ___Yes ___ No Have you ever broken a bone ? Which bone was broken? _____ Age this occurred? _____ How? _____ ___Yes ___ No Have you had back surgery? Have you had hip surgery? ___Yes ___ No ___Yes ___ No Have you lost 2 inches or more in height? ___Yes ___ No Do you have chronic bowel disease? IBS___ Crohn s ____ Weight loss surgery _____ Other_____ ___Yes ___ No Do you take Cortisone, Prednisone or other Steroids?

4 How Long?_____ Dose_____ ___Yes ___ No Have you been diagnosed with rheumatoid arthritis? ___Yes ___ No Do you take thyroid medicine? ___Yes ___ No Do you take calcium (including TUMS) and/or vitamin D? Dosage? _____ ___Yes ___ No Do you take any medicine for osteoporosis? How long? _____ Actonel, Atelvia, Boniva, Evista, Forteo, Fosamax, Prolia, Reclast, Miacalcin Nasal Spray (Circle those that apply) ___Yes ___ No Are you currently receiving Chemotherapy for cancer?

5 How long?_____ ___Yes ___ No Have you ever been diagnosed with osteoporosis _____ or osteopenia _____ ___Yes ___ No Do you have a family history (parent or sibling) of osteoporosis? If so, have they broken a bone ? ___Yes ___ No GYNECOLOGIC HISTORY ___Yes ___ No Are you in menopause? If you are post- menopause, approximate age of last period _____. ___Yes ___ No Have you had a hysterectomy? If so, age: _____ Were your ovaries removed?

6 ___Yes ___ No ___Yes ___ No Do you take hormone therapy in any form at this time? If so, what type? _____ ___Yes ___ No Are you currently taking any type of contraception by shot or an implant, such as Depro- Provera that is intended to stop your periods? LIFESTYLE ___Yes ___ No Do you currently smoke?

7 If so, how much per day _____ ___Yes ___ No Do you exercise regularly? ___Yes ___ No Do you get exposure to sunlight? ___Yes ___ No Do you drink coffee #_____/day tea#_____/day soda#_____/day or alcohol #____/day MID-ATLANTIC IMAGING CENTERS SCHEDULING PROTOCOLS FOR MAMMOGRAMS bone DENSITY BREAST ULTRASOUND Thank you for choosing Mid-Atlantic Imaging Centers to have this important healthcare exam(s) performed. Our friendly and experienced staff is ready to give you personal, professional service using the latest digital equipment.

8 Please read the instructions carefully that are provided below. Failure to comply may result in MAIC not being able to perform your exam at your scheduled date or time. SCREENING MAMMOGRAM: Annual exam; you or your doctor has found NO problems with either breast. *If you find a problem before you come in for your screening mammogram you must see your doctor for a script as the mammogram will change to a diagnostic exam. A. Been seen at MAIC before: you must bring current insurance card, picture ID, and any script your doctor may have given you. B. Not been to MAIC before: you must bring current insurance card, picture ID, previous mammogram for comparison (if done within the Hampton Rhodes area) and a script from your doctor. DIAGNOSTIC MAMMOGRAM: Diagnostic test; you MUST have a script from your doctor.

9 You or your doctor has found a specific problem (lump, mass, localized pain, nipple discharge). Your doctor has examined the breast(s) and written a detailed script describing the problem. C. Been seen at MAIC before: you must bring your current insurance card, a picture ID, and a detailed script from your doctor. D. Not been to MAIC before: you must bring your current insurance card, a picture ID, previous mammogram for comparison (if done within the Hampton Rhodes area) and a detailed script from your doctor. BREAST ULTRASOUND: Diagnostic test; your doctor has examined the breast(s) in question and written a detailed script describing the problem or the radiologist has recommended an ultrasound based on something seen on a recent mammogram. E. Been seen at MAIC before: you must bring current insurance card, picture ID, and any script your doctor may have given you if a recent mammogram has not been performed.

10 F. Not been to MAIC before: you must bring current insurance card, picture ID, previous or recent mammogram (if applicable) and a detailed script from your doctor. bone DENSITY : Diagnostic test; you MUST have a script from your doctor with a diagnosis. Do not take a calcium supplement the day of your exam. You must bring your current insurance card and a picture ID. LATE POLICY: Please arrive 15 minutes early. If you are running late and arrive after your scheduled appointment time, you will be advised that you have become a work-in . In fairness to our patients who are on time, we will do your exam(s) but we cannot guarantee how long you may have to wait IMAGING CENTERSM ammographyBreast UltrasoundBone Densitometry MID-ATLANTIC IMAGING CENTERS A division of Mid-Atlantic women s Care, PLC 6353 Center Drive, Suite 100 Norfolk, VA 23502 AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION Patient Name: _____ Date of Birth: _____ Phone: H) _____ Phone: C) _____ Address: _____ City/State/Zip: _____ Please Note: Copy Fee May Be Charged For Medical Record Above listed patient authorizes the following healthcare facility to make record disclosure: Facility Name: Mid-Atlantic Imaging Centers Facility Phone: _____ Facility Address: _____ Facility Fax: _____ City, State, Zip.