Find Out About Your Bone Health

Bone Health and Osteoporosis Risk Factors

Osteoporosis can develop gradually, often without noticeable symptoms until a fracture occurs. This questionnaire reviews common bone-health risk factors and can help you decide whether it may be worth discussing bone density screening or a DEXA scan with the Bailey Health team.

Bone Health Questionnaire

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Phone

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Name*

Email for quiz result*

1. Please indicate your sex*

Male

Female

2. How old are you?*

3. How much calcium do you consume each day?*

For example, one cup of milk or fortified alternative beverage contains 300 mg calcium.

Less than 1000 mg

More than 1000 mg

Not sure

4. Do you take a vitamin D supplement?*

Yes, I take between 400 – 1000 IU of Vitamin D daily

Yes, I take between 1000 – 2000 IU of Vitamin D daily

Yes, I take more than 2000 IU of Vitamin D daily

I do not take a vitamin D supplement

5. Are you physically active with moderate to vigorous activity for at least a total of 2 1/2 hours per week?*

Yes

No

6. How many alcoholic drinks do you consume each day (including weekends) on average?*

0-1

2-5

6-10

10+

7. Do you currently smoke cigarettes?*

Yes

No

8. Have you lost 2 cm (3/4”) or more in height as measured by your healthcare provider, or 6 cm (2 ½”) or more overall from when you were a young adult?*

Yes

No

Not sure

9. Has your mother, father, or a first-degree relative been diagnosed with osteoporosis?*

Yes

No

Not sure

10. Has either your mother or father had a hip fracture?**

Yes

No

Not sure

11. Have you broken a bone from a simple fall or bump since age 40? (For example, a fall from tripping over uneven ground.)*

Yes

No

12. Have you ever been treated with any of the following medications? Please select all that apply.

Some medications may be relevant to bone-health assessment:

13. Do you have any of the following conditions? Please select all that apply.

Please specify

14. Have you had one or more falls in the last year or do you have any concerns with your balance?*

Yes

No

15. Have your periods ever stopped for several months or longer?

(Other than during pregnancy, menopause, or polycystic ovarian syndrome.)

Yes

No

16. At what age did menopause begin for you?

(Naturally, after surgery, or due to another cause such as medication.)

At 44 or younger

At 45 or older

Have not reached menopause

Would you like us to contact you about a DEXA scan?*

No, thanks

Yes, please

Phone*

Untitled*

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