Find A Doctor
Pay A Bill
Join Our Team
Contact Us
Contact Us
Get Directions
Weglot Switcher
Patients & Visitors
Visiting Hours
Make an Appointment
Patient Portal
Insurance & Billing
Medical Records
On-Site Amenities & Dining Options
Health Information Center
Gift Shop
University Pharmacy
Locations
Parking & Directions
Patient Experience
Medical Care
Medical Services
Find A Doctor
UT Urgent Care
Regional Health Centers
Specialty Practices
Directory of Services
Department Directory
Procedures & Treatments
Centers of Excellence
Brain & Spine Institute
Cancer Institute
Emergency & Trauma Center
Heart Lung Vascular Institute
Orthopaedic Institute
Primary Care Collaborative
Center for Women & Infants
Academics & Research
Academic Medical Center
Graduate School of Medicine
Pharmacy Residency Programs
School of Computerized Tomography
School of Medical Laboratory Science
School of Radiography
School of Vascular Interventional Radiography
Research
Clinical Trials
Health Care Professionals
Referring Physicians
Nursing Excellence
Careers
Education & Training
Team Member Resources
About
Our Story
Excellence & Achievements
UT Medical Center’s Mission, Vision and Values
Events Calendar
Connect
Newsroom
Diversity, Equity and Inclusion
Give Back
COVID-19 Donations and Support
Give Now
Ways to Give
Volunteer
0
Cart
Flu Visitor Restrictions In Effect
Learn More
Patients & Visitors
Visiting Hours
Make an Appointment
Patient Portal
Insurance & Billing
Medical Records
On-Site Amenities & Dining Options
Health Information Center
Gift Shop
University Pharmacy
Locations
Parking & Directions
Patient Experience
Medical Care
Medical Services
Find A Doctor
UT Urgent Care
Regional Health Centers
Specialty Practices
Directory of Services
Department Directory
Procedures & Treatments
Centers of Excellence
Brain & Spine Institute
Cancer Institute
Emergency & Trauma Center
Heart Lung Vascular Institute
Orthopaedic Institute
Primary Care Collaborative
Center for Women & Infants
Academics & Research
Academic Medical Center
Graduate School of Medicine
Pharmacy Residency Programs
School of Computerized Tomography
School of Medical Laboratory Science
School of Radiography
School of Vascular Interventional Radiography
Research
Clinical Trials
Health Care Professionals
Referring Physicians
Nursing Excellence
Careers
Education & Training
Team Member Resources
About
Our Story
Excellence & Achievements
UT Medical Center’s Mission, Vision and Values
Events Calendar
Connect
Newsroom
Diversity, Equity and Inclusion
Give Back
COVID-19 Donations and Support
Give Now
Ways to Give
Volunteer
Breast Center-Osteoporosis Risk Factors
Forms Directory
Breast Center-Osteoporosis Risk Factors
Hidden
Submission Date
MM slash DD slash YYYY
Hidden
Submission IP
Personal Information
First Name
*
Last Name
*
Email
*
Phone
*
Gender
*
Male
Female
Date of Birth
*
Month
Day
Year
Ethnicity
*
African American
Asian
Caucasian
Hispanic/Latino
Other
Height
*
Weight
Medical History
Referring Physician
Medications
Please list all medications, vitamins and calcium supplements you take currently.
Do you presently smoke tobacco?
*
Yes
No
If yes, how much?
Have you ever smoked tobacco?
*
Yes
No
If so, how much
Do you currently drink alcohol?
*
Yes
No
If so, how much?
Have you ever consumed alcohol?
*
Yes
No
If so, how much?
How many times per week do you exercise?
*
How long do you exercise at a time?
Is your diet low in calcium?
*
Yes
No
I don't know
Have you had any x-rays in the last two weeks?
*
Yes
No
If yes, what type(s) of x-rays?
Have you had a hysterectomy?
*
Yes
No
If yes, when?
Were your ovaries removed?
Please provide detail if possible.
Are you postmenopausal?
*
Yes
No
If yes, at what age?
Do you take female hormones?
*
Yes
No
Do you take male hormones?
*
Yes
No
Have you had any broken bones in your adult life?
*
Yes
No
If so, what bones and when were they broken?
Have you ever had bone or joint surgery?
*
Yes
No
If so, when and what bones or joints?
Have you lost any height since high school?
*
Yes
No
Have you ever had cancer?
*
Yes
No
If so, what type and when?
Have you ever taken steroids on a regular basis?
*
Yes
No
Do you have a family history of osteoporosis?
*
Yes
No
If yes, what relation(s)?
Do you have any known diseases or disorders?
*
Yes
No
If yes, what type(s)?
Please provide as much detail as possible
Have you ever had a bone density test before?
*
Yes
No
If yes, when and where?
I hereby authorize and request the release of my bone density study:
*
Agree
Disagree
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
0
Start typing and press Enter to search
Chat with us
, powered by
LiveChat