Osteoporosis Care Monitoring Sheet

Patient Information

Name: _________________ Date of Birth: _________________ Provider: _______________ Next Appointment: ______________

Bone Density (DXA) Scan Records

Medication Tracking

Current Osteoporosis Medications

• Medication Name: _________________ Dose: _______
• Start Date: __________ Schedule: __________
• Notes: _________________________________

Calcium & Vitamin D Supplements

• Daily Calcium Intake Goal: ________mg
• Daily Vitamin D Goal: ________IU

Fall Prevention Checklist

• Home safety assessment completed
• Vision checked within past year
• Balance exercises discussed with provider
• Medications reviewed for fall risk

Exercise Log

Track minutes of activity:

• Weight-bearing exercise: _____ mins/week
• Resistance training: _____ mins/week
• Balance exercises: _____ mins/week

Risk Factor Monitoring

• Smoking Status: □ Never □ Former □ Current
• Alcohol intake: ____ drinks/week
• Recent falls: □ Yes □ No Date(s): _________

Notes & Questions for Next Visit

Emergency Contacts

Name: _________________ Phone: _________________ Relationship: _________________