Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Osteoporosis and Fracture History Form
Patient Name *
Date of Birth
____ / ____ / ________
Previous Fractures
Family History of Osteoporosis
Calcium Intake Assessment
Fall History
Bone Density Test History
Current Medications
| Medication | Dose | How often |
|---|---|---|
Menopause Status
Known Allergies
| Allergy | Reaction |
|---|---|
Osteoporosis and Fracture History Form template from formisoft.com. formisoft.com/intake-templates/osteoporosis-fracture-history