OSTEOPOROSIS QUESTIONNAIRE Dr [Insert name here]
Addressograph label Dr [Insert name here] □
Name MRN
Hospital [Location 1] [Location 2]
Phone No. [Location 3] [Location 4]
Age : ………. [Location 5]
Male Female
Date of current Fracture: / / . Clinic Attendance Date / / .
Aboriginality –Y □ N □
Agree to participate in project Y N
Accommodation - Home Hostel Nursing Home
Source of referral: Specialist E.D. Fracture Clinic Rehabilitation GP Rheumatology
Site of fractures: Humerus Radius Ulna Colles’
This fall Hand Tibia Fibula Foot Spine
Prox. Femur/NOF Distal Femur Ribs Pelvis Other
Treatment for Osteoporosis prior to fracture: No treatment Calcium VitD Fosamax Actonel Evista Rocaltrol Didronel HRT Testosterone Calcitonin Zometa/Aclasta Protos
Forteo Other Name…………….
Treatment for Osteoporosis post fracture: No treatment Calcium VitD Fosamax Actonel Evista Rocaltrol Didronel HRT Testosterone Calcitonin Zometa/Aclasta Protos
Forteo Other Name……………..
What treatment was started ……………….
Where was it started: Clinic G.P. Inpatient Self
Osteoporosis risk factors Yes No Number of fractures
Hx of previous fracture ………………………
Hx of Maternal hip fracture ………………………
Chronic liver/renal failure
Exercises less than 3 times a week (20 mins weight bearing)
Currently Type of exercise……………………
Falls History No of previous falls
Drug History
Oral steroids Meds………………………
Sedatives/psychotropic drugs ……………………..
Anticonvulsant drugs ……………………..
More than 4 prescribed medication …………………….
Total number per day ………….. …………………….
P.T.O
Weight
Height
BMI will be calculated
Age at Menopause?
Not Applicable
Unknown
<35
35 to 45
45 to 50
>50 yrs
HRT longer than 1 year yes no
Calcium intake; Unknown 1Serve = 200mls milk,
1 serve a day = cheese matchbox size
2 Serves/day = tub of yoghurt
3 Serves / day
>3 Serves/day
Current Weekly Alcohol Intake: Nil
1-3 standard drinks/week 4-6 Standard drinks/week
7-11 Standard Drinks/week >11standard drinks/ week
Smoker: Current Former Never
Tests completed: BMD Not required Yes
Spine Femur
Femur T-score Normal > -1
Spine T-score Osteopenic -1 to -2.5 Osteoporosis less than -2.5
Vitamin D: Not Required Yes Vit D Results
Issues for referral to GP Yes No
What ……………………………………..
COMMENTS:
Education: Diet Exercise Calcium Vitamin D Other ………..
Falls Education booklet
Referral to Falls Prevention group
Referral to Over 50 Exercise Group