SURVEY FOR PERSONS WHO HAVE TAKEN PRESCRIBED DRUGS FOR THEIR BONES

You are being invited to participate in a research study about the experiences and any complications people have who took and/or are still taking prescribed drugs for their bones. You were selected to participate in this study because you may have taken one or more prescribed medications for your bones. The purpose of this study is to find out more about who is at risk to experience fractures of their bones during (or after) taking one or more of these drugs. If you agree to take part in this study, please click on the "I agree box" in Question 1 below and then you can begin the  anonymous online survey. This survey will ask how long you took these drugs and whether you had any bones break during or after you took these drugs. The survey will take you approximately 10-20 minutes to complete depending on the number and types of medications you have taken. Your participation in this study is completely voluntary and you can withdraw at any time. You are free to skip any question you choose, or to check off that you do not wish to respond to any particular question(s).
You will not be compensated for being part of this study
Your participation will be anonymous, as maintained by:
- Your computer’s IP address tracking will be disabled, which means we will not be able to know what computer was used to type in the information you provide. This makes the survey anonymous
- Secure Sockets Layer (SSL) encryption will be enabled, which means that the data will be protected as it moves from your computer and SurveyMonkey servers
- The data, once retrieved from Survey Monkey*, will be maintained on a password-protected computer that only the researchers will have access to.

This study is being done by Jane Corrarino DNP, (RN) Nursing Consultant, Jennifer Schneider PhD, MD (Professional Boundaries, Inc.), and Karla Damus, PhD, MSPH, MN, RN (Boston University School of Medicine). If you have any questions or concerns please contact Dr. Jane Corrarino at 631.255.8807 or Dr. Jennifer Schneider at 520-990-7886.

*The SurveyMonkey Privacy Policy and Security Statement can be accessed by clicking on either of those links.

Thank you for participating in our online survey. 

This survey has five sections: 1) Your history of taking prescribed drugs for your bones. 2)  Your activity level during and after taking these drugs. 3) Complications when you too these drugs. 4) A little bit of information about you, and 5) Additional information you may want to add.  If you want to learn what the results of this survey are, please contact Dr. Corrarino at janecorrarino@yahoo.com.

Please answer as many questions as you can. Notice that there are several tables of questions that go across the top of the table from left to right. MOVE THE CURSER ACROSS THE SCREEN TO ACCESS BOXES THAT APPEAR TO BE CUT OFF ON THE SIDE.

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* 1. By clicking “I agree” below you are indicating that you are at least 18 years old, have read and understood this consent statement and agree to participate in this study. Please print a copy of this page for your records. Please DO NOT type in your name anywhere on the survey.

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* 2. Did you take any of these drugs listed here? Fosamax (alendronate), Actonel (risedronate) and/or Boniva (ibandronate)? If no, skip to question 5.

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* 3. Did you take any of the drugs listed here?

  Have you ever taken each of the listed drugs? Year you began Month you began Took drug for how long? (years) Are you still taking this drug? Dose of Drug - initial dose (mg) Dose of Drug - highest dose (mg) If not sure of dose - select "unsure"
Fosamax (alendronate)
Actonel (risedronate)
Boniva (ibandronate)

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* 4. Did you take any of the drugs listed here? (continued)

  Reason you took this drug? How often you took this drug according to how it was prescribed by the doctor? Reason for stopping the drug
Fosamax (alendronate)
Actonel (risedronate)
Boniva (ibandronate)

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* 5. Did you ever take Aredia (pamidronate disodium), Prolia (denosumab), Reclast or Zometa (zolendronate) and/or another drug? If no, skip to question 8.

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* 6. Did you take any of the drugs listed here?

  Have you ever taken each of the listed drugs? Year you began Month you began Took drug for how long? (years) Are you still taking this drug? Dose of Drug - initial dose (mg) Dose of Drug - highest dose (mg) If not sure of dose - select "unsure"
Aredia (pamidronate disodium)
Prolia (denosumab)
Reclast / Zometa (zolendronate)
Other (please enter name of drug in comments below):

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* 7. Did you take any of the drugs listed here? (continued)

  Reason you took this drug? How often you took this drug according to how it was prescribed by the doctor? Reason for stopping the drug
Aredia (pamidronate disodium)
Prolia (denosumab)
Reclast / Zometa (zolendronate)
Other (please enter name of drug in comments below):

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* 8. Your activity level during and after taking these drug(s). Think back to how physically active you were while you were taking these drug(s). Compared to other people you know, how would you describe your level of physical activity during that time (Note: if you have had a fracture of your thigh bone (femur), this time frame should only include the period before your first [or only] femur fracture).

  Overall activity level Running Walking Swimming Lifting Weights Riding Bike
Activity Level

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* 9. Your CURRENT activity level as compared to others your age

  Overall activity level Running Walking Swimming Lifting Weights Riding Bike
Activity Level

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* 10. Complications other than fractures. While you took any of these drugs, did  you have any of the following problems? (Check all that apply).

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* 11. Have you had one or more fractures since taking any of these drugs?

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* 12. If you have had at least one or more fractures, enter your fracture history (year of occurrence) for each fracture

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* 13. Have you ever taken calcium or vitamin D?

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* 14. Calcium/Vitamin D form

  Year Started Year Stopped Dosage: Amount per day (mg) Year restarted (if you restarted it) Year restopped (if you restopped) Dosage when restarted (mg)
Calcium
Vitamin D

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* 15.  This question and the next few tell us a little about you. It will be very helpful if you can answer all these questions, since it will help us know more about some of the things that may be linked with having fracture(s) or not having them after taking these prescribed drugs(s). Your answers are anonymous.
How old are you?

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* 16. How tall are you now?

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* 17. If you have lost some height as an adult, approximately how many inches?

  inches lost
Please select from drop down:

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* 18. What is your weight now (in pounds)?

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* 19. What is your ethnicity?

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* 20. Gender

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* 21. Your smoking history

  Have you ever smoked? I smoke now and have been smoking for ____ years
Smoking Information

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* 22. If you have smoked, about how many cigarettes per day?

  Amount
smoked:

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* 23. If you have any of these health problems, please check all that apply:

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* 24. Thank you for filling out this survey. Please use the space below if you would like to tell us anything else.

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