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Osteoporosis Risk Questionnaire

Risks You Can Change

Do you smoke cigarettes? yes no
Do you have 3 or more cups of coffee a day - or an equivalent amount of caffeine from other sources, such as cola-type beverage? yes no
Do you drink alcoholic beverages?
Do you avoid milk and other dairy products? yes no
Do you exercise regularly? (Regular exercise being 20-30 minutes of weight-bearing exercise 2-3 times a week i.e. walking, aerobics, bicycling.) yes no
Are you a female who exercises a great deal, with irregular or no menstruation? yes no
Do you have an eating disorder or consume too little nutritious food? yes no
Do you have high amounts of fiber in your diet? More than 5 servings of fruit &/or vegetables. Plus 6 to 11 servings of whole grains bread and cereals. yes no
Is your diet high in animal protein, such as red meats? More than 8 oz per day. yes no
Do you add salt to foods at the table? yes no
Are you a vegetarian, or have a diet heavily weighted toward vegetables? yes no


Risks You Cannot Change

Are you female? yes no
Are you white, northern European, or Asian? yes no
Do you have a fair complexion yes no
Do you have a small boned frame? yes no
Are you over 40 years of age? yes no
Are you over 70 years of age? yes no
Do you have a family history of osteoporosis or other bone disease? yes no
Have you had children? yes no
Have you breast-fed at least one child?
Have you had both your ovaries removed? yes no
Did your menopause occur before age 45? yes no


Risks You Might Be Able to Change

Have you had arthritis or curvature of the spine? yes no
Have you ever used steroid (cortisone) drugs? yes no
Have you had an overactive thyroid gland with symptoms such as a fast pulse and heart rate, loss of wight, and "hyped up" body metabolism? yes no
Have you had hyperparathyroidism, an excessive secretion of the parathyroid glands, which causes loss of calcium from the bones, formation of cysts in the bones, and kidney stones? yes no
Have you had biliary cirrhosis (an inflammatory disease of the bile system connecting the liver and the intestines)? yes no
Do you have chronic kidney disease? yes no
Have you ever used anticonvulsants (medications designed to prevent convulsions or fits)? yes no
Have you had stomach or small-bowel disease? yes no
Do you take stomach acid blockers such as Zantac, Prilosec, Tagamet, etc? yes no
Are you allergic to milk or other dairy products? yes no



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