The Healthy Woman®

Osteoporosis Risk Factor Questionnaire
Please complete the following questions to the best of your ability. If you are unsure, leave the space blank and we will help you with the answer. This information will help us assess your risk for Osteoporosis.

Today's date: _____/_____/_____
Name _________________________________________________________________
Age ______ Sex: F___ M____
Race: Asian ___ Afro-American ___ Caucasian ___ Hispanic ___ Other ________
Height: ______ Weight: _____ Referring Physician: _________________________
Do you have any metal hardware in your back or hip?
Yes ___ No___
If yes, where is it located? ______________________________________________
Did you ever have a bone fracture in your adult life (after 21)?
Yes ___ No___
If yes, where and at what age? __________________________________________
Have you had surgery on your hip or spine (back)?
Yes ___ No___
Do you have a family history of Osteoporosis?
Yes ___ No___
Have you lost height since high school?
Yes ___ No___
Do you have scoliosis?
Yes ___ No___
Do you smoke tobacco?
Yes ___ No___
Do you drink more than two alcoholic beverages a day?
Yes ___ No___
Do you exercise at least two or three times a week
Yes ___ No___
Do you have frequent falls?
Yes ___ No___
Have you ever taken steroids (prednisone)?
Yes ___ No___
Are you currently taking steroids (prednisone)?
Yes ___ No___
Have you gone through Menopause?
Yes ___ No___
Did your menopause occur before age 40?
Yes ___ No___
Have you ever taken any estrogen hormones?
Yes ___ No___
Are you now taking any Estrogens?
Yes ___ No___
Do you take Calcium Supplements?
Yes ___ No___
If yes, what type and how much? ________________________________________
Please list all medical conditions for which you are being treated:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Please list all your current medications:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Any other information you feel is important:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Would you like us to send a copy to your Physician?
If yes, what is the Physician's name? __________________________________
Remember, all bone density machines are not the same. For greater accuracy,
repeat follow-up tests should be done on the same machine. Your results are
kept on our machine and as new software and technology become available,
we will be better able to determine your progressive changes by upgrading
and comparing the older with the newer tests.