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 ⁯ ⁯ ⁯ completed: BMD Not required Yes ⁯ ⁯ Spine 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 ⁯ ……….. Falls Education booklet ⁯ Referral to Falls Prevention group ⁯ Referral to Over 50 Exercise Group ⁯
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 ⁯ completed: BMD Not required ⁯ Yes ⁯ Spine 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 ⁯ ……….. Falls Education booklet ⁯ Referral to Falls Prevention group ⁯ Referral to Over 50 Exercise Group ⁯