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OSTEOPOROSIS HISTORY

Gender
Are you retired?
Marital Status
May we contact you about clinical trial participation if Dr. Rudolph feels one of our trials would be beneficial to you?
Ethnic Background

DIET AND HABITS

Do you have lactose or dairy intolerance?
(1 serving is a glass of milk, an ounce of cheese, a cup of cottage cheese, or a container of yogurt.)
Do you salt your food?
Do you exercise?
Do you smoke?
Do you consume alcohol?

BROKEN BONES

What bone fractures have you had, how did they happen, and how old were you at the time?

FAMILY HISTORY

YOUR HISTORY

Please check any of these illnesses you have had and explain below if necessary:

For Females:

Did you take estrogen?

For Males:

Do you have testosterone deficiency?
Do you have erectile dysfunction?
Do you get regular dental care?

MEDICAL HISTORY

If yes, what medications, when did you start them, when did you stop them, and did you have problems with them and if so, what problems.

Appealing Insurance Denials

I authorize NMCROC to enact appeals on my behalf to my primary and secondary (if applicable) insurance carriers as it relates to denials for the following: in-office treatment, authorized injectable medications, claim denials, prescription medication and durable medical equipment. I understand that by allowing NMCROC to appeal denials on my behalf, I am not guaranteed a positive outcome.

Thank you for filling out this history form. The doctor will fill in any missing details at your visit.