The
following is a survey for individuals who have suffered
a broken bone (fracture). Please answer only those questions
that apply to you.
Date
of Birth
Gender
Male
Femal
Race
Caucasian
African-American
Asian
Hispanic
other
What
made you fall?
I
have problems walking
The
sidewalk was uneven or broken, it was icy, windy (environmental conditions)
Because
I was in a hurry and did not pay attention (or someone
pushed me)
Other
I
did not fall, I broke a bone while
You
have a broken bone. Has this happened to you before?
Yes
No
If yes, when did you break a bone?
How old were you?
Which bone did you break?_(check all that apply)
Wrist
ankle
foot
ribs
spine
hip
Why
do you think you broke a bone (fracture) Check all that
apply:
I
broke because I fell
I
broke a bone because my bones are brittle
(osteoporosis)
Other
Do
you have a regular physician?
Yes
No
If
yes, have you discussed osteoporosis with your
physician?
Yes
No
If
you have suffered a broken bone before, Did you mention
this to your family doctor?
Yes
No
If no, why did you or not mention it?
(check all that apply)
I did not think it mattered
I thought something might be wrong with me I did not have time to discuss it with my doctor
Doesn’t everyone break a bone at sometime?
If
you mentioned it to your doctor, did he/she mention
osteoporosis?
Yes
No
Other
Was
a bone density test (DEXA) ordered?
Yes
No
Other
If
you were given an order for a DEXA (bone density test),
did you have it done?
Yes
No
Why
yes? (check all that apply)
I think it is a reasonable thing to do I want to find out so I can prevent future fractures I want to stay young and independent as long as
possible
Why not? (check all that apply) I do not believe osteoporosis could happen to me
Most women would have broken if they would have
fallen as hard as I did I do not believe in looking for problems
If I am found to have the disease, I don’t want to
take medications
If I am found to have the disease, I can’t afford
the medications
Why have testing if I have no problems or symptoms?
I do not have medical insurance
I am too busy, taking care of … ( check all that apply )
children
spouse
(significant other) part
time job
full
time job
parents
home
other
If
we were to suggest having a bone density test and
evaluation for osteoporosis, would you be willing to
have it done?
Yes
No
Would
youhesitate
having this testing (bone density testing )done now?
I
do not believe osteoporosis could happen to me
I
do not have health insurance
If
I am found to have the disease, I don’t want to take
medications
If
I am found to have the disease, I can’t afford the
medications
Why
have testing if I have no problems or symptoms?
Other
Do
you believe in prevention as a means to stay healthy?
For
instance some tests are done on seemingly healthy patients
in an effort to help them remain free of disease. These
include breast self exam, mammogram, colonoscopy and flu
shots among others. In general, would you say you receive
these tests regularly or not?
Yes
No
Which of the following tests
have you had done in the past two years?
Mammogram
Yes
No
PAP
smear
Yes
No
Stool
for blood
Yes
No
Flu
shot
Yes
No
Colonoscopy
Yes
No
Pneumovax
Yes
No
Bone
density
Yes
No
If
no, could you describe what might keep you from getting
these tests done?
I
do not have a family doctor
I
do not go to the doctor when I feel fine, only when I
am sick
I
do not have health insurance
I
am afraid of finding out that something is wrong with
me
Other
In
general would you say you take care of yourself by doing
the following
Exercising
(running, walking, working out at the gym, swimming
etc) at least 30 minutes 5 times/week
Exercising
as above 3 times/week
Exercising
less than once /wee
Only
household activities (or gardening)
I
am on my feet less than 4 hrs per day
None
of the above
Is
your diet low in fat and do you watch your cholesterol?
Yes
No
A glass of milk, a slice of cheese, a cup of yogurt
equals one calcium serving = 250 mg calcium) If so, then how
much calcium do you consume in diet on a daily basis? less than 250 mg/day (less than one serving)
250-500 mg/day
500-750
mg/day
750-1000
mg/day
more
than 1000 mg/day (more than 4 servings)
I
take calcium supplements
I
take a multivitamin
Have
you heard about osteoporosis medications? (check all
that apply)estrogen
calcitonin
Fosamax
Actonel
Evista
Tibolone
PTH
Do
you believe that these medications could reduce your
chance of having a broken spine or broken hip?
Yes
No
Rank
the following problems as to the likelihood of them
occurring to you from
1 (most likely) to 5 (least likely):
Breast cancer
12345
Heart attack
12345
Hip Fracture
12345
Stroke
12345
Other
12345
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