FLS Bone Health TeleECHO™ Clinic Case Study Survey

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4. If female, menopausal state:

Premenopausal

Perimenopausal

Postmenopausal

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5. Age at menopause:

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6. Ethnicity:

Hispanic/Latino

Not Hispanic/Latino

Prefer not to say

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7. Race:

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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8. What is your main question about this case? (Required.)

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9. General Health Status:

Poor

Good

Excellent

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10. Physical Activity Level:

Non-weight bearing

Sedentary

Active

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11. Nutrition-Food intolerances:

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12. Falls (how many time per year?):

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13. Fractures: Age, Type, Circumstances

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14. Family History:

Celiac Disease

Hyperparathyroidism

Osteoporosis

Fractures

Other (please specify)

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15. Medical History:

GERD

Endocrine Hyperparathyroidism

Hyperparathyroidism

Difficulty Swallowing

Diarrhea

Diabetes

Malabsorption

Malignancy

Rheumatoid Arthritis

Radiation Therapy

Celiac Disease

Autoimmune Disease

Poor Oral Hygiene

Previous Surgery

Other (please specify)

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16. Current Medications/Vitamins/Herbs/Supplements (list: medication, start date, dosage, frequency):

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17. Previous Osteoporosis Medication (list: medication, start date, end date, reason stopped):

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18. Previous Bone-Toxic Medications (list: start & end date and indication):

Prednisone

Aromatase Inhibitors

Androgen Deprivation Rx

Anticonvulsant

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19. Smoking History - Does this patient currently smoke?

Yes

Quit recently

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20. Alcohol Consumption-Average more than 2 drinks daily?

Yes

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21. Physical Exam:

Date:

Height:

Historical Maximum Height:

Weight:

BMI:

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22. Focused Bone Related Findings:

Blue Sclera

Rash

Thyomegaly

Kyphosis

Spine Tenderness

Dental Issue

Muscle Strength Issue

Rib Pelvis Space

Balance Issue

Mobility Issue

Assistive Devices

Other (please specify)

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23. DXA (report T-score or Z-score, as appropriate; scan images if possible):

Date

L1L4

Total Hip

Femoral Neck

33% Radius

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24. Upload scanned images here:

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25. Vertebral imaging results:

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26. FRAX clinical risk factors:

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27. Current lab results:

CBC

Creatine

eGFR

Alk Phos

Calcium

Phosphorus

Albumin

Bone Turnover Marker (NTX, CTX)

PTH

TSH

25-OH-D

Serum Protein Electrophoresis

K/L Light Chain Ratio

24-hour Urinary Calcium

Celiac Antibodies

Tryptase

Other

FLS Bone Health TeleECHO™ Clinic Case Study

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* 1. Presenter Name: (Required.)

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* 2. Patient Age:

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* 3. Biologic Gender:

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* 4. If female, menopausal state:

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* 5. Age at menopause:

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* 6. Ethnicity:

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* 7. Race:

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* 8. What is your main question about this case? (Required.)

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* 9. General Health Status:

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* 10. Physical Activity Level:

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* 11. Nutrition-Food intolerances:

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* 12. Falls (how many time per year?):

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* 13. Fractures: Age, Type, Circumstances

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* 14. Family History:

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* 15. Medical History:

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* 16. Current Medications/Vitamins/Herbs/Supplements (list: medication, start date, dosage, frequency):

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* 17. Previous Osteoporosis Medication (list: medication, start date, end date, reason stopped):

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* 18. Previous Bone-Toxic Medications (list: start & end date and indication):

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* 19. Smoking History - Does this patient currently smoke?

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* 20. Alcohol Consumption-Average more than 2 drinks daily?

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* 21. Physical Exam:

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* 22. Focused Bone Related Findings:

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* 23. DXA (report T-score or Z-score, as appropriate; scan images if possible):

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* 24. Upload scanned images here:

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* 25. Vertebral imaging results:

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* 26. FRAX clinical risk factors:

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* 27. Current lab results:

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* 28. FLS Program Question:

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* 29. Additional Comments:

1. Presenter Name: (Required.)

2. Patient Age:

3. Biologic Gender:

4. If female, menopausal state:

5. Age at menopause:

6. Ethnicity:

7. Race:

8. What is your main question about this case? (Required.)

9. General Health Status:

10. Physical Activity Level:

11. Nutrition-Food intolerances:

12. Falls (how many time per year?):

13. Fractures: Age, Type, Circumstances

14. Family History:

15. Medical History:

16. Current Medications/Vitamins/Herbs/Supplements (list: medication, start date, dosage, frequency):

17. Previous Osteoporosis Medication (list: medication, start date, end date, reason stopped):

18. Previous Bone-Toxic Medications (list: start & end date and indication):

19. Smoking History - Does this patient currently smoke?

20. Alcohol Consumption-Average more than 2 drinks daily?

21. Physical Exam:

22. Focused Bone Related Findings:

23. DXA (report T-score or Z-score, as appropriate; scan images if possible):

24. Upload scanned images here:

25. Vertebral imaging results:

26. FRAX clinical risk factors:

27. Current lab results:

28. FLS Program Question:

29. Additional Comments: