Our Physicians
Dr. Rick Muckerman
Dr. George Ahlering
Dr. Christi Menges
About Us
Locations
Office
Where we operate
Where we deliver
Our Nurse Practioner
Practice history
Our Services
3-D ultrasound
Bone density testing
Gynecology services
In-office procedures
Mammography
OB services
Surgery Center procedures
Front Desk
Appointments
Insurance carriers
Patient Forms
New Patient Forms
DXA test (Bone density)
Medical History
Gynecology Visit
Disclose Information
Office policies
DXA test (Bone Density)
Please fill out the form below and hit the Submit button at the bottom.
Date
2/22/2012
Physician
Age of Menopause
Patient Name (first, middle, last)
Ethnicity(Choose one)
Asian
Black
Hispanic
White
Other
Adult (over 20 years of age) Fractures
Femur
Forearm
Humerus
Pelvis
Spine
Patient History (Please check all that apply)
Older than 65 years of age
Hyperparathyroid 252.0
Amenorrhea (missed periods/no periods) 626.0
Hyperthyroid 242.90
Anorexia nervosa 307.1
Hypothyroid 244.9
Both ovaries removed 256.39
Low Body Weight 783.22
Cigarette smoker 305.11
Osteoporosis 733.01
Crohn's Disease 555.9
Osteopenia 733.90
Cushing's Syndrome 255.0
Poor/frail health v69.1
Dementia 294.8
Postmenopausal (1 year w/o period) 627.2
Diabetes 250.0 (Also Insulin dependent E932.3)
Hysterectomy 627.4
Early menopause (Before age 45) 256.31
Recurrent Falls E888.8
Family history of osteoporosis v17.81
Kidney Disease (renal failure) 593.9
Height loss 781.91
Rheumatoid Arthritis 720.0
Adult Fracture (within 2 years) E887
Sedentary v69.0
Medications (Please check all that apply)
Current
Previous
Current
Previous
Actonel v58.83
Evista v58.83
Anticonvulsants v58.69,E936.3
Forteo v58.83
Atelvia v58.83
Fosamax v58.83
Boniva v58.83
Heparin use
>27 v58.61,E934.2
Calcitonin
Lupron v58.83,E932.0
calcium
Prolia v58.83
Corticosteriods v58.69
Thiazide
Depo Provera v58.69
Vitamin D
Estrogen
Other-
Evista v58.83
Other-