Induction Form

Yoga vs. Osteoporosis Study Form:

 All Prospective Yoga vs. Osteoporosis Study Participants Should Fill-out the Form Below:

In order to participate in the Yoga vs. Osteoporosis study headed by Dr. Loren Fishman, you need to the acquire from our office (without cost) or watch it for free daily at https://www.youtube.com/watch?v=o8SjystaH-E.

The data below can be obtained when your physician next draws blood and takes urine. If you need a separate prescription to direct an independent lab such as Quest or Athena to conduct the proper tests, please email or fax us. Otherwise, just give this paper to your physician, and fax or email the results to: Email (preferred): liza@sciatica.org, or Fax:  Attn: Yoga Vs. Osteoporosis (212) 472-4127.

Necessary Lab Tests (done within 6 months of study entry):

TSH (Thyroid stimulating hormone)

PTH (Parathyroid hormone)

ESR (Erythrocyte sedimentation rate)

SMA – 18 (standard electrolyte, liver and kidney function tests)

Vitamin D 25 – OH

Vitamin D 1,25 – Dihydroxy

Urine NTX (a measure of reabsorbed collagen cross-linkages)

Each applicant must also supply a current DEXA scan (done within 6 months of application), and a second DEXA performed at least one year in the past.

When we have received the induction form, the laboratory reports, your two bone mineral density test (DEXA scans) reports, and, optionally, recent hip and lumbar spine X-rays, and once Dr. Fishman has reviewed them, and any abnormal values have been corrected, you will be inducted into the study and we will mail you a DVD for use on the days when you are not practicing your certified yoga teacher.

Please allow one-two weeks for processing. If there are questions, please email Loren@sciatica.org or liza@sciatica.org

The video of the poses is also available at https://www.youtube.com/watch?v=o8SjystaH-E.

Yoga vs. Osteoporosis Study Form Osteoporosis Induction form

Date_______________________________________ Name______________________________________ Phone______________________________________ Email_______________________________________ Address_____________________________________ ____________________________________________

Date of Birth__________________________________ Female/ Male?

Weigh____________ Height___________ Greatest Height_______Hysterectomy? Yes No

First monthly period_____/_____ Last monthly period_____/_____ Orchiectomy? Yes No

Do you take Calcium? Y N *Daily Dose________ Brand/Type______________

Date started ________________________

Do you take Vitamin D? Y N * Daily Dose_______ Brand/Type______________

Date started ________________________

Do you take Magnesium? Y N * Daily Dose______ Brand/Type______________

Date started ________________________

Other medicine for osteoporosis? Y N * Daily Dose_________ Brand/Type______________ Date started ________________________

Previous medicines for osteoporosis? Y N * Daily Dose_________ Brand/Type______________ Date started ________________________

Names, Dosage of all other medicines/supplements/vitamins: _________________ __________________________________________________________________

Exposed to Steroids? Y N Dosage and Dates___________________________

Birth Control? Y N Daily Dose_________ Brand/Type______________

Dates taken__________________________ Hormone Therapy? Y N Daily Dose_________ Brand/Type______________ Dates taken__________________________ Unusual Nutrition? (e.g., vegan for 20 years) ___________________________

History of Bone Fractures? _________________________________________

Yoga Practice? a. Years of Yoga______________________________________

Type of yoga (e.g., Vinyasa, Iyengar)___________________

c. How often and how long? (e.g., 1 x per week, 30 min/day_______________

d. How consistent? (e.g., never miss, miss every few weeks, skip weeks at a time, etc.) _____________________________________________

Other Exercise? What Type? (e.g., Swimming) ___________________________

a. How often? (e.g., 1 x per week) ___________________________

b. How long per session? ________________________________

c. How consistent? _____________________________________

Last DEXA scan_______________________

Last Hip/Lumbar X-rays_________________

Family History (Please mention any family history of osteoporosis): __________________________________________________________________ __________________________________________________________________ ________________________________________________________________

Medical Conditions, including hip and spine surgeries: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Comments: ________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________

Please scan the results into an email and send them to liza@sciatica.org.  If the results of any of the blood or urine studies are abnormal, Dr. Fishman will direct you to the proper type of physician to help bring your values in line. Once that has occurred, you will be admitted to the study.

N.B.  Dr. Fishman recommends, but does not require, that participants take the following supplements:

If you are under age 75, Dr. Fishman recommends taking 1500 mg calcium, 1500 iu of vitamin D3, and 250 mg magnesium, preferably as a chelate with amino acids.

If you are over age 75, Dr. Fishman recommends taking 500 mg calcium, 1500 iu of vitamin D3, and 250 mg magnesium, preferably as a chelate with amino acids.