Name *

First Name

Last Name

1. Have either of your parents been diagnosed with osteoporosis or broken a bone after a minor fall (a fall from standing height or less)?

Yes

No

2. Did either of your parents have a stooped back (dowager's hump)?

Yes

No

3. Are you 40 years old or older?

Yes

No

4. Have you ever broken a bone after a minor fall, as an adult?

Yes

No

5. Do you fall frequently (more than once in the last year) or do you have a fear of falling because you are frail?

Yes

No

6. After the age of 40, have you lost more than 3 cm in height (just over 1 inch)?

Yes

No

7. Are you underweight (is your Body Mass Index less than 19 kg/m2)?

Yes

No

8. Have you ever taken corticosteroid tablets (cortisone, prednisone, etc.) for more than 3 consecutive months (corticosteroids are often prescribed for conditions like asthma, rheumatoid arthritis, and some inflammatory diseases)?

Yes

No

9. Have you ever been diagnosed with rheumatoid arthritis?

Yes

No

10. Have you been diagnosed with an over-active thyroid, over-active parathyroid glands, type 1 diabetes, or a nutritional / gastrointestinal disorder such as Crohn's, Celiac or Irritable Bowel disease?

Yes

No

11. For women over 45: Did your menopause occur before the age of 45?

Yes

No

12. Have your periods ever stopped for 12 consecutive months or more (other than because of pregnancy, menopause, or hysterectomy)?

Yes

No

13. Were your ovaries removed before age 50, without you taking Hormone Replacement Therapy?

Yes

No

14. Have you ever suffered from impotence, lack of libido or other symptoms related to low testosterone levels?

Yes

No

15. Do you regularly drink more than 2 units of alcohol a day?

Yes

No

16. Do you currently, or have you ever, smoked cigarettes?

Yes

No

17. Is your daily level of physical activity less than 30 minutes per day (housework, gardening, walking, running etc.)?

Yes

No

18. Do you avoid, or are you allergic to milk or dairy products, without taking any calcium supplements?

Yes

No

19. Do you spend less than 10 minutes per day outdoors (with part of your body exposed to sunlight), without taking vitamin D supplements?

Yes

No