NP Form – Dr. Lewiecki (ID #2636)

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Sex
Ethnic Group:
Are you retired?
Have you had a bone density test?
Have you had X-rays, CT scan, or MRI of your spine?
Have you ever had X-ray therapy for any reason?
Are you interested in participating in an osteoporosis research study if you qualify?
Osteoporosis Risk Factor Assessment
YesNo
Have you lost more than 2 inches in height?
Yes
No
Have you ever broken a bone? (list your age, date, and circumstances for every fracture below)
Yes
No
Does your mother, father, brother, or sister have osteoporosis?
Yes
No
Has your mother, father, brother, or sister broken bone since age 40?
Yes
No
Do you smoke cigarettes?
Yes
No
Do you have more than two drinks of an alcoholic beverage per day?
Yes
No
Do you weigh less than 127 lbs?
Yes
No
Do you have rheumatoid arthritis?
Yes
No
Do you have kidney failure?
Yes
No
Have you had vitamin D deficiency?
Yes
No
Do you have lactoce intolerance?
Yes
No
Any difficuly with digestion?
Yes
No
Have you ever had hyperthyroidism (an overactive thyroid gland)?
Yes
No
Have you had hyperparathyroidism, or a high calcium level in your blood?
Yes
No
Do you have inflammatory bowel disease, such as Crohn's disease?
Yes
No
Do you have intestinal malabsorption, such as celiac disease?
Yes
No
Have you had a gastrectomy (part of your stomach removed)?
Yes
No
Have you ever had an eating disorder?
Yes
No
Have you had an organ transplant?
Yes
No
Have you fallen in the last year?
Yes
No
Do you have a walking or balance problem?
Yes
No
Do you have to push off on the arms of a chair to stand up?
Yes
No
Do you have any problems with infection or pain in your teeth or jaw?
Yes
No
Do you have any oral surgery or tooth extractions planned or scheduled?
Yes
No
Do you have any ongoing problems with your teeth or jaw?
Yes
No
Are you allergic to any medicines? (list below)
Yes
No

Please check to indicate any RECENT symptoms.

GENERAL
EYES
ENT
ENDOCRINE
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
UROLOGICAL
NEUROLOGICAL
SKIN
HEMATOLOGICAL
MUSCULO-SKELETAL
OSTEOPOROSIS

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.