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Bone Health Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Do you have low bone density or osteoporosis?*:

Yes No

Do you have a family history of osteoporosis?*:

Yes No

Have you lost height?*:

Yes No

Do you suffer from general poor health?*:

Yes No

Do you take any long-term medications known to increase the risk of osteoporosis? (cortiocosteroids, heparin, anti-seizure medications)*:

Yes No

Do you suffer from immobility?*:

Yes No

Do you have hyperparathyroidism or hyperthyroidism?*:

Yes No

Do you have a gastrointestinal issue that causes malabsorption?*:

Yes No

Do you consume excess caffeine or alcohol?*:

Yes No

Do you smoke?*:

Yes No

Do you eat an unhealthy diet?*:

Yes No

Is your diet low in calcium?*:

Yes No

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

Yes No

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

Yes No

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

Yes No

Are you a woman with low estrogen levels?*:

Yes No

Are you a postmenopausal woman?*:

Yes No

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