Study Site: Date: Form completed by: Clinic Logs will be picked up by Tamsin Hughes each week on behalf of the Physiotherapy Research Unit Tel: 37424 – Patient initials Willing to be contacted by the Prove PIS Eligibility Criteria Eligible? DoB research team? > 18 years Yes YES No Yes Osteoporosis No Day Time Telephone Reason: confirmed by number: Doesn’t have time for No radiology Reason if no: study……⃝ Vertebral Osteoporosis due to other Not willing to travel ………………………………… disease/medication……………⃝ for study...⃝ fracture in past Predominantly mechanical back with ……………………………….. 12 mths radicular leg pain ………⃝ Backache in Unstable Please state: past 12 mths (NOT-radiating condition…………………………….⃝ to leg) Other (Please Specify)…….....⃝ ……………………………………………… > 18 years Yes YES No Yes Osteoporosis No Day Time Telephone Reason: confirmed by number: Not happy to be No radiology Reason if no: randomised….⃝ Vertebral Osteoporosis due to other Doesn’t have time for disease/medication……………⃝ study……⃝ fracture in past Predominantly mechanical back with Not willing to travel 12 mths radicular leg pain for study...⃝ ………⃝ Backache in Unstable past 12 mths Please state: (NOT-radiating condition…………………………….⃝ to leg) Other (Please Specify)……....⃝ …………………………………………………………
Study Site: Date: Form completed by: Clinic Logs will be picked up by Tamsin Hughes each week on behalf of the Physiotherapy Research Unit – Tel: 37424 Eligibility Criteria Patient initials DoB Eligible? Willing to be contacted by the Prove research team? PIS > 18 years Osteoporosis confirmed by radiology Vertebral fracture in past 12 mths Backache in past 12 mths (NOT-radiating to leg) Yes No Reason if no: Osteoporosis due to other disease/medication……………⃝ Predominantly mechanical back with radicular leg pain ………⃝ Unstable condition…………………………….⃝ Other (Please Specify)…….....⃝ ……………………………………………… YES Day Time Telephone number: ………………………………… ……………………………….. No Reason: Doesn’t have time for study……⃝ Not willing to travel for study...⃝ Please state: Yes No > 18 years Osteoporosis confirmed by radiology Vertebral fracture in past 12 mths Backache in past 12 mths (NOT-radiating to leg) Yes No Reason if no: Osteoporosis due to other disease/medication……………⃝ Predominantly mechanical back with radicular leg pain ………⃝ Unstable condition…………………………….⃝ Other (Please Specify)……....⃝ ………………………………………………………… YES Day Time Telephone number: No Reason: Not happy to be randomised….⃝ Doesn’t have time for study……⃝ Not willing to travel for study...⃝ Please state: Yes No