Personal Information Form | Division of Endocrinology

Introductory Information

Name:

*

Gender:

*

Male

Female

Date of Birth:

*

(mm/dd/yyyy)

Race:

*

Street:

*

City:

*

State:

*

Zip Code:

*

Phone Number (Day):

(x-xxx-xxx-xxxx)

Phone Number (Evening):

*

(x-xxx-xxx-xxxx)

Phone Number (Cell):

(x-xxx-xxx-xxxx)

E-Mail Address:

Female History

Have you experienced menopause?:

*

Yes

No

Date of Last Menstrual Period:

*

Estimate if unsure; (mm/yyyy)

Type of Menopause?:

*

Natural

Surgical

Were both ovaries removed?:

*

Yes

No

Are you currently taking estrogen (hormones) for menopause?:

*

Yes

No

Start date for current or past use of estrogen:

(mm/dd/yyyy)

Stop date for past use of estrogen:

(mm/dd/yyyy)

Total years of post-menopausal estrogen use:

*

Medical History

Are you currently taking prescription medication for osteoporosis?:

*

Yes

No

Actonel®, Boniva®, Boniva®Injection, Evista®, Forteo®, or Miacalcin®

Medication Name:

*

Start Date:

*

(mm/dd/yyyy)

Stop Date:

*

(mm/dd/yyyy) or N/A if still taking medication

Medication Name:

Start Date:

(mm/dd/yyyy)

Stop Date:

(mm/dd/yyyy) or N/A if still taking medication

Have you previously taken prescription medication for osteoporosis?:

*

Yes

No

Actonel®, Boniva®, Boniva®Injection, Evista®, Forteo®, or Miacalcin®

Medication Name:

*

Start Date:

*

(mm/dd/yyyy)

Stop Date:

*

(mm/dd/yyyy) or N/A if still taking medication

Medication Name:

Start Date:

(mm/dd/yyyy)

Stop Date:

(mm/dd/yyyy) or N/A if still taking medication

During the last 6 months, have you taken any steroid medications?:

*

Yes

No

Prednisone, Medrol Dose Pack, Cortisone (oral, inhaled, or injection)

Medication Name:

*

Start Date:

*

(mm/dd/yyyy)

Stop Date:

*

(mm/dd/yyyy) or N/A if still taking medication

Have you ever smoked?:

*

Yes

No

Start Date:

*

(mm/dd/yyyy)

Stop Date:

*

(mm/dd/yyyy) or N/A if still smoking

Years as a smoker:

*

Packs smoked per day:

*

Have you ever had a fracture or broken bone?:

*

Yes

No

(wrist, hip, leg, arm)

Bone Broken:

*

Fracture Date:

*

(mm/dd/yyyy)

Bone Broken:

Fracture Date:

(mm/dd/yyyy)

Bone Broken:

Fracture Date:

(mm/dd/yyyy)

Bone Broken:

Fracture Date:

(mm/dd/yyyy)

Have you ever had a history of cancer, other than basal cell skin cancer?:

*

Yes

No

Type of Cancer:

*

Date of Diagnosis:

*

(mm/dd/yyyy)

Cancer Treatment (check all that apply):

Chemotherapy

Radiation therapy

Surgery

Height (inches):

*

Weight (lbs.):

*

Authorization

I give Creighton University Osteoporosis Research Center (ORC) permission to add the above information into its confidential database files so that I may be contacted for future research opportunities at the ORC, provided the Creighton University Institutional Review Board approves such access and uses. This authorization has no expiration date.

Authorization:

*

Yes, I agree to the above statement

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