Osteoporosis Questionnaire

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Are you at risk for developing osteopenia or osteoporosis? Take this survey to determine your estimated risk. Stay tuned for the next write up on increasing bone density and dietary guidelines to prevent bone loss.

Choose the item in each category that best describes you, and write down the point value for that item. The points are the numbers listed to the right. You may chose more than one item in categories with an asterisk (*).

Frame Size

Small-boned or petite = 10
Medium frame, very lean = 5
Large frame, very lean = 5
Medium frame, average or heavy build = 0

Ethnic Background

Caucasian= 10
Asian= 10
Other= 0

Activity Level – How often do you walk briskly, jog, engage in aerobic activity, or perform hard physical labor of a duration of at least 30 minutes?

Seldom = 30
1-2 times per week= 20
3-4 times per week= 5
5 or more times per week= 0

Smoking

Smokes 10 or more cigarettes a day = 20
Smokes fewer than 10 cigarettes a day =10
Quit smoking = 5
Never smoked = 0

Other Health Factors*

Family history of osteoporosis = 20
Long-term corticosteroid use = 20
Long-term anticonvulsant use = 20
Drinks more than 3 glasses of alcohol/wk = 20
Drinks more than 1 cup of coffee per day = 10
Seldom gets outside in the sun = 10
Has had ovaries removed and has not used hormone therapy = 10
Premature menopause without the use of hormone therapy =10
Has never had a child = 10

Dietary Factors*

Consume > 4 oz of red meat per day = 20
Drink soft drinks regularly = 20
Consumes 3-5 servings of vegetables/day = –10
Consumes > 1cup of green leafy vegetables/day = -10
Takes a calcium/magnesium supplement= -10
Consumes primarily a plant based whole food diet= -10