Dr. Rudolph’s New Patient Form

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GENERAL INFORMATION

Are you retired?
Married, Single, Widowed, Divorced, Separated, Other
May we contact you about clinical trial participation if Dr. Rudolph feels one of our trials would be beneficial to you?

DIET AND HABITS

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

BROKEN BONES

Please answer the following three questions for each fracture. If you’ve never had a fracture, skip this section.

STRENGTH AND BALANCE

Have you lost strength?
Do you use a walking aid or mobility aid?
Do you have problems getting out of a chair?
Have you had a fall?
Do you have balance problems?

FAMILY HISTORY

Do any of your blood relatives have osteoporosis?
Do any of your blood relatives have osteopenia*?
*Low bone density
Has anyone in the family had a bone fracture?
We are particularly interested in hip fractures.

YOUR HISTORY

Are you allergic to any medications?
Please check next to any of these illnesses you have had an explain below if necessary:

MEDICAL HISTORY

Do you get regular dental care?
Have you taken medications for osteoporosis or osteopenia?
Are you taking prednisone or other steroids?
Are you taking drugs to control the immune system?
Are you taking drugs for prostate cancer?
Do you take a multivitamin?
Do you take Strontium?
Are you taking medication for acid reflux or other stomach conditions?
Are you taking antidepressants?

CALCIUM

Do you take calcium?

OTHER MEDICATIONS

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.
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Contact

300 Oak Street NE, Albuquerque, NM 87106

Medical Practice

Phone:505-855-5525

Fax: 505-884-4006

Billing:505-855-5525

Emergency: 505-857-3844

Research Center

Phone: 505-855-5505

Fax: 505-855-5506

Emergency: 505-857-3844

Study Recruiter: 505-923-3232