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Osteoporosis and Bone Metabolism Disorders

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/Osteoporosis and Bone Metabolism Disorders
/Application Form

Osteoporosis and Bone Metabolism Disorders

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

Weight (kg)

If you have any other complaints, please describe them

Reason for Application

What is the main reason for applying to our council?

Osteoporosis (T-score -2.5 or below)

Osteopenia (Low Bone Mass - T-score between -1.0 and -2.4)

History of Low-Energy Fracture (spine, hip, wrist, etc.)

Secondary Osteoporosis (due to cortisone use, rheumatic disease, etc.)

Early Menopause or Hormone-Related Bone Loss

Other / Preventive Consultation

Other

Diagnosis and Treatment History

When was osteoporosis or bone loss first detected?

Have you received any osteoporosis treatment so far?

Yes

If yes, which ones?

Bisphosphonates (alendronate, zoledronic acid, etc.)

Denosumab (injection)

Teriparatide / Anabolic (Bone-Building) Treatments

Calcium and Vitamin D Supplements

Hormone Replacement Therapy (HRT)

Other / None

Other

Complaints and Risk Factors

What complaints do you currently have?

Loss of height or rounded back (kyphosis)

Chronic back and lower back pain

Bone fractures after simple falls or minor trauma

Limited mobility and tiring quickly

Other

Is there a family history (especially a parent) of hip fracture or severe osteoporosis?

Yes

I don't know

Lifestyle and Habits

Smoking

Regular alcohol consumption

Sedentary lifestyle / lack of exercise

Insufficient calcium intake

Bone Densitometry (DEXA)

Date

Lumbar Spine T-score

Femoral Neck (Hip) T-score

Total Femur T-score

Laboratory Results

Date

Serum Calcium

Phosphate

25-OH Vitamin D

Parathyroid Hormone (PTH)

Thyroid Tests (TSH)

Bone Turnover Markers (CTX, P1NP, etc., if available)

Medications and Other Conditions

Do you have a history of regular cortisone (corticosteroid) or similar medication use?

Yes

Duration and dose

Other chronic conditions (diabetes, rheumatism, digestive malabsorption disorders, etc.)

For Female Patients: Age and Type of Menopause

Your Questions for the Council

Question 1

Question 2

Question 3

Tests and Reports

No tests

Bone Densitometry (DEXA) Report

Spine X-ray or MRI/CT Reports

Blood and Urine Test Results

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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