|
The more you
answer "yes" to these questions, the greater your risk of osteoporosis. |
|
General Personal Information |
|
1.)
|
Are you female? |
 Yes
No |
|
2.)
|
Are you Caucasian or of Northern European ancestry?
|
Yes
No |
|
3.)
|
Are you Asian or Hispanic? |
Yes
No |
|
4.)
|
Do you have a thin, small-boned frame? |
Yes
No |
|
5.)
|
Do you have a very lean build, weigh less than 127 pounds, or have a body
fat percentage that is less than 15 percent of your total body weight? |
Yes
No |
|
6.)
|
Are you over the age of 50? |
Yes
No |
|
7.)
|
Are you over the age of 65? |
Yes
No |
|
Personal Physical
Characteristics |
|
8.)
|
Have you lost over an inch in height?
|
Yes
No |
|
9.)
|
Do you have dowager's hump (forward stooping over of your mid-spine)? |
Yes
No |
|
10.)
|
Do you have frequent low back pain? |
Yes
No |
|
11.)
|
Have you ever broken a bone and had a vertebral compression fracture or
experienced a fracture of your hip, wrist, pelvis, rib, or foot as an
adult? |
Yes
No |
|
12.)
|
Have you ever had a stress fracture? |
Yes
No |
|
Family History |
|
13.)
|
Does your
mother have a diagnosis of osteoporosis? |
Yes
No |
|
14,)
|
Does your
sister or brother have osteoporosis? |
Yes
No |
|
15.)
|
Does your
grandmother have osteoporosis? |
Yes
No |
|
16.)
|
Do you have an
immediate female family member who has broken a bone as an adult? |
Yes
No |
|
Nutrition |
|
17.)
|
Is your diet
low (less than 3 servings a day) in sources of calcium such as milk and
other dairy products? |
Yes
No |
|
18.)
|
Is your diet
high in animal protein (more than 3 times a week) such as red meat? |
Yes
No |
|
19.)
|
Are you a
strict vegetarian, or do you have a diet primarily weighted toward
vegetables and fruits alone? |
Yes
No |
|
20.)
|
Do you have
poor nutrition or poor eating habits such as skipping meals? |
Yes
No |
|
21.)
|
Do you drink
two or more cola-type beverages daily? |
Yes
No |
|
22.)
|
Do you drink
three or more cups of coffee per day? |
Yes
No |
|
23.)
|
Do you obtain
less than 800 IUs per day of Vitamin D? |
Yes
No |
|
24.)
|
Do you obtain
less than twenty minutes of natural sunlight a day? |
Yes
No |
|
Social History |
|
25.)
|
Do you smoke
cigarettes now or have you smoked cigarettes regularly in the past? |
Yes
No |
|
26.)
|
Do you drink
two or more alcoholic beverages a day or do you drink alcohol to excess?
|
Yes
No |
|
Exercise and Body
Conditioning |
|
27.)
|
Do you
consider your muscles weak? |
Yes
No |
|
28.)
|
Do you perform
aerobic weight-bearing (i.e. walking) and muscle strengthening/toning
exercises less than three times weekly? |
Yes
No |
|
29.)
|
Are you
physically inactive in your work or daily routines? |
Yes
No |
|
30.)
|
Is your health
so poor that you are not able to perform your Activities of Daily Living (ADLs)
such as getting dressed, bathing, and preparing meals? |
Yes
No |
|
31.)
|
Have you
experienced a fall or are you at increased risk for falling (i.e. unstable
from poor health/frailty, postural dizziness, blacking out, fainting
spells)? |
Yes
No |
|
Female History
(men should proceed to the "Male History"
section) |
|
32.)
|
Are you a
postmenopausal woman? |
Yes
No |
|
33.)
|
Have you had a
hysterectomy with surgical removal of your ovaries? |
Yes
No |
|
34.)
|
Have both your
ovaries been removed before natural menopause? |
Yes
No |
|
35.)
|
Did you
experience menopause before the age of 45? |
Yes
No |
|
36.)
|
Did your first
menstrual period begin after the age of 15?
|
Yes
No |
|
37.)
|
Are you past
your menopause and not taking hormone replacement therapy? |
Yes
No |
|
38.)
|
Have your
menstrual periods stopped because of intensive exercise? |
Yes
No |
|
39.)
|
Have your
menstrual periods stopped for one reason or another for over a year?
|
Yes
No |
|
40.)
|
Are your
menstrual periods scarce and irregular? |
Yes
No |
|
41.)
|
Have you not
had children (nulliparity)? |
Yes
No |
|
Male History
(women should proceed to the "Medication History" section) |
|
42.)
|
Do you have a
decrease in testosterone (commonly known as the male hormone) or
experience impotence (difficulty in or inability to achieve penile
erection or ejaculate? |
Yes
No |
|
43.)
|
Do you have
decreased testicular function (male hypogonadism)? |
Yes
No |
|
44.)
|
Are you
receiving Lupron, (a Gonadotropin-releasing hormone) to treat prostate
cancer? |
Yes
No |
|
Medication History |
|
45.)
|
Do you take
steroid or cortisone-like drugs (i.e. prednisone)? |
Yes
No |
|
46.)
|
Do you take
thyroid hormone medication which might be excessive? |
Yes
No |
|
47.)
|
Do you take
anticonvulsants for seizures or epilepsy such as phenobarb or phenytoin (Dilantin®)?
|
Yes
No |
|
48.)
|
Do you
regularly take aluminum containing antacids such as Maalox®
or Mylanta®?
|
Yes
No |
|
49.)
|
Do you take
Loop diuretics or water pills such as Lasix®, Bumex®, or Edecrin®? |
Yes
No |
|
50.)
|
Do you take
Lithium, isoniazid, methotrexate, or heparin? |
Yes
No |
|
51.)
|
Have you had
chemotherapy for cancer? |
Yes
No |
|
52.)
|
Do you take
multiple medications or practice polypharmacy? |
Yes
No |
|
Medical History |
|
53.)
|
Have you ever
had an X-ray report which said you had demineralization or loss of bone
density? |
Yes
No |
|
54.)
|
Do you have
hyperthyroidism (overactive thyroid)? |
Yes
No |
|
55.)
|
Do you have
hyperparathyroidism (overactive parathyroids)? |
Yes
No |
|
56.)
|
Do you have
insulin-dependent diabetes mellitus? Do you have rheumatoid arthritis?
|
Yes
No |
|
57.)
|
Do you have
chronic obstructive pulmonary disease such as emphysema or chronic
bronchitis? |
Yes
No |
|
58.)
|
Do you have
Paget's disease of bone? Do you have multiple myeloma, lymphoma, or
leukemia? |
Yes
No |
|
59.)
|
Do you have an
eating disorder such as bulimia or anorexia? |
Yes
No |
|
60.)
|
Do you have
liver disease? |
Yes
No |
|
61.)
|
Have you had
part of your stomach removed or had stomach by-pass surgery?
|
Yes
No |
|
62.)
|
Do you have a
malabsorption syndrome such as Crohn's disease or sprue?
|
Yes
No |
|
63.)
|
Do you have a
chronic intestinal disease such as irritable bowel disease (IBS)? |
Yes
No |
|
64.)
|
Do you have
lactose intolerance or any other nutritional disorders which interfere
with intestinal absorption? |
Yes
No |
|
65.)
|
Do you have
chronic renal insufficiency or failure? Do you have sarcoidosis or
multiple sclerosis? |
Yes
No |
|
66.)
|
Do you have
pernicious anemia, endometriosis, thalassemia, hyperprolactonemia,
systemic mastomycosis, congenital porphyria, hemophilia, osteogenesis
imperfecta, malacia, Ehrlers-Danlos syndrome, or homocystinuria? |
Yes
No |
|
67.)
|
Do you have
prolonged immobilization or partial or complete paralysis of an extremity?
|
Yes
No |
|
68.)
|
Have you had
an organ transplant? |
Yes
No |
|
69.)
|
Do you have
multiple chronic medical conditions which are causing you poor health,
frailty, and lack of ability to perform your normal daily activities?
|
Yes
No |
|
End
of Personal Osteoporosis Risk Assessment |
