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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

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Osteoporosis Screening Questionnaire

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:


Advanced Clinical Nutrition
, Wichita Falls, Tx
76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com


Osteoporosis Fracture Risk Assessment Questionnaire
Statistical Data:  Average Risk for U.S. Caucasians = 50% chance of osteoporotic fracture.

Yes    No 1. I am 65 years of age or older
Yes    No 2. I am Caucasian or Asian living in the U.S.
Yes    No 3.* I am underweight or have lost weight since age 25.
Yes    No 4. I am physically inactive and rarely exercise.
Yes    No 5.* I am weak; for example I cannot rise from a chair without using my arms.
Yes    No 6. I rank my overall health as poor.
Yes    No 7. I was taller than my peers at age 25.
Yes    No
8. I spend less than 30 minutes three times a week outdoors in the sunshine.
Yes    No 9. My resting pulse is 80 beats or more per minute.
Morning Pulse:
Yes    No 10. I generally do not consume milk, yogurt or cheese daily. (Prefer non-cow)
Yes    No 11. I generally consume less than one serving per day of green leafy vegetables (collards, kale, broccoli, bok choy, dandelion greens, etc.)
Yes    No 12. I eat meat, fish or other flesh foods more than once a day.
Yes    No 13. I regularly add salt to my food.
Yes    No 14. I use canned or packaged foods more than twice a day.
Yes    No 15. I use sugar or have sweetened foods more than twice a day.
Yes    No 16. I drink two or more cups of coffee, or four or more cups of tea or chocolate daily. (Caffeine teas, black, Lipton teas, etc.)
Yes    No 17. I consume two or more colas or soft drinks daily.
Yes    No 18. I eat fast foods two or more times a week.
Yes    No 19.* I presently smoke.
Yes    No 20. I used to smoke.
Yes    No 21. I have two or more alcoholic drinks per day.
Yes    No 22.* I regularly use or have regularly used over long periods of time glucocorticoids, such as Prednisone.
Yes    No 23.* I use anti-convulsant drugs such as Dilantin.
Yes    No 24.* I use tranquilizers and mood-altering drugs.
Yes    No 25. I used Depo Provera for several years.
Yes    No 26. I use aluminum-containing antacids on a daily basis (e.g., Rolaids, Maalox, Mylanta, Gelusil, etc.)
Yes    No 27.* One of my parents fractured a hip.
Yes    No 28.* I have documented low bone density (2 l/2 standard deviations or more below young normal values). My bone density is:
Yes    No 29.* I experienced a fracture after age 50.
Yes    No 30. I have receding gums or periodontal disease.
Yes    No 31. I have false teeth.
Yes    No 32. I have thin, transparent skin.
Yes    No 33. I have little muscular development.
Yes    No 34. I have weak, brittle fingernails.
Yes    No 35. I suffer frequent indigestion, gas, bloating, belching or diarrhea.
Yes    No 36. I have regular nocturnal leg cramps.
Yes    No 37. I have undergone intestinal or stomach surgery.
Yes    No 38. I have an overacid thyroid.
Yes    No 39. I am lactose intolerant or allergic to dairy products.
Yes    No 40. I frequently feel light-headed if I stand up quickly.
Yes    No 41.* There were times when my period stopped for many months (not including pregnancy, lactation or menopause).
Yes    No 42. Menopause was naturally early (before age 43)
Yes    No 43. Menopause was surgically induced by ovary removal.

Answer Key:
     Each of the above questions may be associated with the development of osteoporosis and an increased risk of osteoporotic fracture. The greater your number of "Yes" answers, the more reason for you to begin a serious osteoporosis-prevention and bone-rebuilding program now.

  • 4 or more "Yes" to questions with an (*), you are likely to be at high risk for an osteoporotic fracture at some point in the future.
  • 8 or more "Yes" questions, you are at average risk.
  • 10 or more "Yes" questions, you are likely at high risk for an osteoporotic fracture

If you scored 4 or more answers with an asterik (*) or your total score is 10 or more, click here to order your clinical and sports nutrition analysis for an osteoporotic corrective and preventive clinical nutrition support program.

Copyright 1996, Susan E. Brown Ph.D

Click the button below to receive your total as well as send your results.



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