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FLS Bone Health TeleECHO™ Clinic Case Study
Complete items on this form and if you have any questions, please e-mail
education@bonehealthandosteoporosis.org
– Attn: FLS ECHO
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*
1.
Presenter Name:
(Required.)
2.
Patient Age:
3.
Biologic Gender:
Female
Male
4.
If female, menopausal state:
Premenopausal
Perimenopausal
Postmenopausal
5.
Age at menopause:
6.
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Prefer not to say
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)
*
8.
What is your main question about this case?
(Required.)
9.
General Health Status:
Poor
Good
Excellent
10.
Physical Activity Level:
Non-weight bearing
Sedentary
Active
11.
Nutrition-Food intolerances:
12.
Falls (how many time per year?):
13.
Fractures: Age, Type, Circumstances
14.
Family History:
Celiac Disease
Hyperparathyroidism
Osteoporosis
Fractures
Other (please specify)
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)
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):
Prednisone
Aromatase Inhibitors
Androgen Deprivation Rx
Anticonvulsant
19.
Smoking History - Does this patient currently smoke?
Yes
No
Quit recently
20.
Alcohol Consumption-Average more than 2 drinks daily?
Yes
No
21.
Physical Exam:
Date:
Height:
Historical Maximum Height:
Weight:
BMI:
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)
23.
DXA (report T-score or Z-score, as appropriate; scan images if possible):
Date
L1L4
Total Hip
Femoral Neck
33% Radius
24.
Upload scanned images here:
Choose File
No file chosen
25.
Vertebral imaging results:
26.
FRAX clinical risk factors:
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
28.
FLS Program Question:
29.
Additional Comments:
Current Progress,
0 of 29 answered
