Bone Density Risk Assessment Questionnaire

Are you concerned that you might be at risk for osteoporosis?

Take our questionnaire to find out.

 
Name :

Email Address:

Age:     Gender:     Race:

Are you aware of a family history of osteoporosis? Yes     No 

What is your body frame type?

Do you exercise regularly (3 or more times per week)? Yes     No

What activities make up your exercise program?

Are you a competitive athlete (play sports on a team)? Yes     No

Do you drink alcohol? Yes     No

    If YES: How many times per week do you drink alcohol?

            When you do drink, approximately how many drinks do you have?

Are you now, or have you ever been a smoker?  Yes     No

        If YES: How long have you / did you smoke?

                How many cigarettes per day do / did you smoke?

Do you drink caffeine? Yes     No

    If YES: What type of caffeine drinks do you drink?

            Approximately how many cups per day do you have?

Do you frequently drink soda? Yes     No     Occasionally only

     If YES: How many ounces per day?

Do you have, or have you had an eating disorder? Yes     No

        If YES: Type of disorder

                How long have you had / did you have the disorder?  

Have you ever had a bone fracture? Yes No

        If YES: Bone that fractured

                Age when fracture took place

Do you / have you used steroid medications (used for asthma, etc.)? Yes No

Do you / have you taken thyroid hormones? Yes     No

Are you currently experiencing menopause? Yes     No        

    If YES: Are you taking medications to assist with symptoms? Yes     No

            What medications are you taking?

Are you lactose intolerant? Yes     No

    If NO: How many dairy servings do you have per day?    

           How many 8 oz. servings of milk do you have per day?  

Do you take calcium supplements? Yes     No