Complete items on this form and if you have any questions, please e-mail andrea.medeiros@nof.org – Attn: FLS ECHO

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* 1. Presenter Name:

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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?

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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:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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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:

0 of 29 answered
 

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