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Osteoporosis Monitoring and Treatment Tracking Sheet

Personal Bone Health Management Record

Endocrinology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________
Date of Birth: _________________
Medical Record #: _________________

Bone Density (DXA) Test Results

Date T-Score Hip T-Score Spine T-Score Wrist Next Test Due

Risk Factors (Check all that apply)

  • Family history of osteoporosis
  • Early menopause
  • Smoking history
  • Low body weight
  • Previous fractures
  • Corticosteroid use
  • Rheumatoid arthritis
  • Calcium/Vitamin D deficiency

Medication Log

Current Medications

Medication Name: _________________
Dosage: _________________
Frequency: _________________
Start Date: _________________

Previous Treatments

Medication Start Date End Date Reason for Discontinuation

Calcium and Vitamin D Supplementation

Daily Calcium Intake Target: _________ mg
Daily Vitamin D Target: _________ IU

Fracture History

Date Location Type Treatment

Exercise Log

Type of Exercise: [ ] Weight-bearing [ ] Resistance [ ] Balance Frequency: _____ times per week Duration: _____ minutes per session

Follow-up Appointments

Date Provider Notes

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