Patient Survey

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
Doesnít 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 donít want to take medications
If I am found to have the disease, I canít 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 Ö ( 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 you  hesitate 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 donít want to take medications
If I am found to have the disease, I canít 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
1           2           3            4            5
Heart attack
1           2           3            4            5
Hip Fracture
1           2           3            4            5
Stroke
1           2           3            4            5
Other   
1           2           3            4            5


Comments:  

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