Bone Health Questionnaire – Natural Health & Wellness Center

Do you have low bone density or osteoporosis?*

Do you have a family history of osteoporosis? *

Have you lost height?*

Do you suffer from general poor health?*

Do you take any long-term medications known to increase the risk of osteoporosis (e.g., corticosteroids, heparin, anti-seizure medications)? *

Do you suffer from immobility? *

Do you have hyperparathyroidism or hyperthyroidism?*

Do you have a gastrointestinal issue that causes malabsorption?*

Do you consume excess caffeine or alcohol? *

Do you smoke? *

Is your diet low in calcium? *

Do you live a stressful lifestyle? *

Do you have low vitamin D intake and limited sun exposure? *

Are you a woman with a thin or small body frame?*

Are you a woman with ammenorhea (loss of the menstrual period)?*

Are you a woman with low estrogen levels?*

Are you a postmenopausal woman?*

Name*

First Last

Phone*

Email*