OSTEOPOROSIS QUESTIONNAIRE Dr [Insert name here] ⁯ Dr [Insert name here] □ label ⁯Addressograph 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 N –Y □ □ 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 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 failure ⁯ ⁯ Exercises less than 3 a week (20 mins weight bearing) ⁯ ⁯ Currently Type of exercise…………………… ⁯ 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
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 ⁯ ⁯ 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 failure ⁯ ⁯ Exercises less than 3 a week ⁯ ⁯ (20 mins weight bearing) Currently ⁯ Type of exercise…………………… 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
osteoporosis-questionnaire.docx