Osteoporosis Risk Factor Questionnaire
- Please check appropriate description:
__ Caucasian __ Asian __ African-American __ Hispanic __ Other
- Do you take any of the following medications regularly (please circle
all that apply):
Synthroid Corticosteroids (Prednisone, etc.) Lasix Dilantin?
- Did your mother, sister, aunt or grandmother break a hip, wrist or
rib after age 45?
__ Yes __ No
- Have your mother, sister, aunt or grandmother ever been diagnosed
with osteoporosis?
__ Yes __ No
- Do you currently smoke cigarettes or have you within the past 7 years?
__ Yes __ No
- During an average week, do you consume more than 7 alcoholic drinks?
( one drink = one beer, mixed alcoholic drink or glass of wine) __ Yes
__ No
- During an average week do you consume more than 14 servings of beverages
with caffeine? (coffee, tea or soft drink – one serving = 1 cup,
can, bottle or glass) __ Yes __ No
- During an average week, do you do LESS THAN 30 minutes of the following
activities, LESS THAN three or more times per week: walking, running,
dancing, bicycle riding, racquet sports, lifting weights, aerobics or
any other physical exercise? __ Yes __ No
- Do you regularly take calcium supplements and/or vitamins? __ Yes
__ No
- Since age 45 have you broken any bones such as: hip, wrist, rib or
ankle? __ Yes __ No
- Have you lost height over your lifetime or been told you have a curve
to your upper back?
__ Yes __ No
{Questions for Women only}
- Were you less than age 45 when your menstrual cycle stopped? __ Yes
__ No
- Has it been at least 5 years since your last menstrual cycle or hysterectomy?
__ Yes __ No
- Are you currently taking Estrogen? (Premarin, Estrace, Estraderm)
__ Yes __ No
- I have never taken estrogen or I have stopped taking estrogen in the
last 6 months.
__ Yes __ No
If you answered yes to more than more than 5 questions you should consider a bone density test to further determine your risk of developing osteoporosis.