Use this treatment worksheet to outline your recommendations for calcium, vitamin D, medications, exercise, and other dietary recommendations. Your physician, physical therapist, registered dietitian, and/or patient educator should help you to fill this out.    

  1. Calcium Recommendations:            

    You need _____ milligrams (mg) of calcium per day (includes both diet and supplements).

    You are getting _____ mg of calcium from your diet each day.

    You need ______mg of calcium recommended from a supplement. 

    Type of supplement: _____ Calcium Carbonate or _____ Calcium Citrate

    Each pill should have _____ mg of calcium and _____  mg of vitamin D                                           


  2. Vitamin D recommendations : 

    You need _____ International Units (IUs) of vitamin D every day.      

                Multivitamin (take with food) _____

                Calcium + vitamin D supplement(s) _____

                Other _____

     Other dietary recommendations:

     ___ Sodium Restriction            ___ Caffeine Restriction


  3. Medications:

    ___ Hormone Replacement Therapy (HRT)

    ___ Evista (Raloxifene)

    ___ Fosamax (Alendronate)

                ___ 70 mg (once per week)

                ___ 10 mg (once per day)

    ___ Actonel (Resedronate)

                ___ 35 mg (once per week)

                ___ 5 mg (once per day)

    ____ Miacalcin (Calcitonin)

    ____ Forteo (PTH/Parathyroid Hormone)

    Medication Instructions:

  4. Exercise/Physical Therapy Recommendations:    

    ___ Walking

    ___ Weight Training

    ___ Other

    ___ Physical Therapy Referral for:

                ___ Neutral Spine Training

                ___ Strengthening

               ___ Fall Prevention

               ___ Balance Training

                ___ Pain Control