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Providers at Alpharetta
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Jason J. Holbrook, M.D.
Margaret M. Still, M.D.
Todd D. Miller, MD
Kaya S. Caldwell, M.D.
Tina H. Strickland, FNP-BC
Providers at Cumming
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Jason J. Holbrook, M.D.
Jennifer D. Cook, M.D.
Marianne Sanchez, M.D.
Lisa Montbellier, PA
Sara W. Wallace, NP-C
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Preventive Care
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Physical Examinations
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Adult Annual Physical Examinations
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Pre-Operative Physical Examination
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Gastrointestinal Care
Cholesterol Maintenance
Diabetes
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Diabetic Retinopathy
Immunizations
Cardiac Care
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Echocardiography
Holter Monitor
Coumadin Clinic
Nephrology & Hypertension
Joint Pain – Rheumatology
Medicare Annual Wellness Visit
Specialty Procedures
Patient Resources
Insurance
Blog
Contact
Main Menu
Patient Portal
Patient Portal
Request Appt
Home
About Us
Our Doctors
Menu Toggle
Providers at Alpharetta
Menu Toggle
Jason J. Holbrook, M.D.
Margaret M. Still, M.D.
Todd D. Miller, MD
Kaya S. Caldwell, M.D.
Tina H. Strickland, FNP-BC
Providers at Cumming
Menu Toggle
Jason J. Holbrook, M.D.
Jennifer D. Cook, M.D.
Marianne Sanchez, M.D.
Lisa Montbellier, PA
Sara W. Wallace, NP-C
Services
Menu Toggle
Primary Care Services
Preventive Care
Cancer Screenings
Physical Examinations
Menu Toggle
Adult Annual Physical Examinations
Sports Pre-Participation Physical Examinations (PPE)
Pre-Operative Physical Examination
Women’s Health
Men’s Health
Gastrointestinal Care
Cholesterol Maintenance
Diabetes
Menu Toggle
Diabetic Retinopathy
Immunizations
Cardiac Care
Menu Toggle
Echocardiography
Holter Monitor
Coumadin Clinic
Nephrology & Hypertension
Joint Pain – Rheumatology
Medicare Annual Wellness Visit
Specialty Procedures
Patient Resources
Insurance
Blog
Contact
Release of Medical Information
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Please enable JavaScript in your browser to complete this form.
Bone Density Questionnaire
Name
*
Date
*
Is there a chance that you are pregnant?
*
YES
NO
Have you a barium x-ray in the last 2 weeks?
*
YES
NO
Have you a barium x-ray in the last 2 weeks? Have you had a nuclear medicine scan or injection of an x-ray dye in the last week?
*
YES
NO
Have you had hyperparathyroidism or a high calcium level in your blood?
*
YES
NO
*IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE, SPEAK TO THE RECEPTIONIST IMMEDIATELY*
2. Your Ethnicity:
*
Caucasian
Black
Asian
Hispanic
Other
Your Ethnicity Other
*
3. Have you ever had a bone density test?
*
YES
NO
If YES, when and where?
*
4. Have you had a recent weight change?
*
YES
NO
If YES, tell us about it
*
5. Your tallest height (late teens or young adult)
*
6. Have you ever broken a bone?
*
YES
NO
Simple Fall?
*
What was your age when the fall occurred
*
If not a simple fall, please describe circumstances below:
*
7. Has a parent or sibling had a broken hip from a simple fall or bump?
*
YES
NO
8. Has a parent or sibling had any other type of broken bone from a simple fall or bump?
*
YES
NO
9. How many times have you fallen in the last year?
*
10. Have you ever had surgery of the spine, hips, legs or arms?
*
YES
NO
If YES, describe what type of surgery and which side was affected.
*
11. Are you currently receiving, or have you previously received prednisone pills (cortisone)?
*
YES, Currently
YES, previously
NO
If YES, how long?
*
What dose? (MG)
*
Pills each day
*
12. Do you smoke?
*
YES
NO
13. Alcohol: 3 or more units per day
*
YES
NO
14. List any chronic medical conditions that you have:
*
15. Are you currently receiving, or have you previously received any of the following medications?
Medication for seizures of epilepsy
*
YES
NO
How long?
*
Chemotherapy for cancer
*
YES
NO
How long?
*
Medication for prostate cancer
*
YES
NO
How long?
*
Medication to prevent organ transplant rejection
*
YES
NO
How long?
*
16. Have you been treated with any of the following medications?
Alendronate (Fosamax)
*
Ever?
Currently?
If current, how long?
*
Boniva
*
Ever?
Currently?
If current, how long?
*
Calcitonin (Miacalcin Nasal Spray)
*
Ever?
Currently?
If current, how long?
*
Hormone Replacement Therapy (Estrogen)
*
Ever?
Currently?
If current, how long?
*
Intravenous Pamidronate (Aredia)
*
Ever?
Currently?
If current, how long?
*
Prolia
*
Ever?
Currently?
If current, how long?
*
PTH (Forteo)
*
Ever?
Currently?
If current, how long?
*
Raloxifene (Evista)
*
Ever?
Currently?
If current, how long?
*
Reclast
*
Ever?
Currently?
If current, how long?
Risedronate (Actonel)
*
Ever?
Currently?
If current, how long?
*
Tamoxifen
*
Ever?
Currently?
If current, how long?
*
Testosterone
*
Ever?
Currently?
If current, how long?
*
Zoledronic Acid (Zometa)
*
Ever?
Currently?
If current, how long?
*
17. How many servings of the following do you eat/drink per day (on average)?
Milk (Full cup) of servings
*
Orange Juice fortified w/ calcium (Full cup) of servings
*
Yogurt (Small container or½ cup) of servings
*
Cheese of servings
*
18. Do you take any calcium supplements (including TUMS)
*
YES
NO
19. Do you take any Vitamin D supplements (including multivitamins & halibut liver oil)
*
YES
NO
FOR WOMEN ONLY
20. Are you still having menstrual periods?
*
YES
NO
21. Before menopause, have you ever missed your-periods for 6 months or more
*
YES
NO
Besides During pregnancy
22. Have you had your menopause? If YES, what age?
*
YES
NO
What age?
*
23. Have you had a hysterectomy? If YES, what age?
*
YES
NO
What age?
*
24. Have you had both ovaries removed? If YES, what age?
*
YES
NO
What age?
*
Submit
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