ELIGIBILITY SURVEY

Patient Information

Title

First Name *

Last Name *

Date of Birth *

Address

Street addressStreet address line 2

Suburb

State

Postcode

Country

Mobile Phone *

Home Phone

Email Address *

Indication

Are you on any of the following drugs?

Aclasta (Zolendronic acid)Prolia (Denosumab)Actonel (Risedronate)Fosamax (Alendronate)Forteo (Teriparatide)Evenity (Romosozumab)

Are you over 70?

YesNo

Have you had a bone density scan before?

YesNoUnsure

Was your bone density scan within the last 2 years?

YesNoUnsure

Have you started any osteoporosis drugs in the last 2 years? (e.g. Prolia, Aclasta, Forteo, Evenity)

YesNo

Have you sustained any fractures without trauma (any broken bone without a fall?)

YesNo

Have you broken a bone from falling from ground level (e.g. not from a height such as stairs, ladders etc...)

YesNo

Do you have any of the following? *

Prolonged and current steroid therapy exposure (e.g. 7.5mg or above of Prednisolone for 3 or more months)Conditions associated with excess steroid secretion?Low testosterone levels (male only)Low oestrogen levels lasting for 6 months or longer (for females aged 45 or under)A high parathyroid or thyroid state (e.g. Graves disease)Rheumatoid arthritisDiarrhoea disorders (e.g. Coelics, Ulcerative Colitis, Crohns disease)Chronic liver diseaseChronic kidney diseaseNone of the above

General Practitioner (optional)

Doctor Name

Clinic Address

Street addressStreet address line 2

Suburb

State

Postcode

Country

Clinic Telehphone

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Phone (03) 9700 7666

Fax (03) 9700 5952