Seneca PT--Osteoporosis Risk Assessment

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15201 Shady Grove Rd. Suite #106
Rockville, MD 20850
Tel: 301-948-4395
Fax: 301-840-8972

Bill Rolle PT, DPT, CSCS

Linda Kuserk PT

Robert Woodside PT, DPT, CSCS

Matt Adams PT, MS

Adam Weaver, PT, DPT

CONGRATULATIONS!

By reading the following information and taking this quiz you are taking an important step toward improving your health!

QUIZ Instructions

A number of factors can contribute to your risk for developing osteoporosis. While you can control some of them, such as smoking, exercise, and diet, others such as age and family history, are beyond your control. To find out more about your personal risk, complete the following form and click the Submit button when finished.

1.	Family History Do you have a close relative (grandparents, parents, brother or sister) who has developed osteoporosis?	Yes No

2.	Ethnicity Are you of Caucasian or Asian descent?	Yes No

3.	Age & Sex

4.	Bone Structure & Body Weight Are you small boned and thin?	Yes No

5.	Hormone Levels Are you a woman experiencing abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), or a man with low testosterone level?	Yes No

6.	Medication History Have you taken any of the following medications? (Steroids, Thyroid Medication, Anti-convulsants, or hormones)	Yes No

7.	Eating Disorder Do you have or have you had anorexia or bulimia?	Yes No

8.	Diet Do you eat 3 or more servings of dairy products per day?	Yes No

9.	Calcium Do you take a calcium supplement or bone health supplement daily?	Yes No

10.	Alcohol/Caffeine Do you consume alcohol/caffeine in excess or have you previously consumed excessive alcohol/caffeine?	Yes No

11.	Smoking Do you smoke?

12.	Exercise Do you participate in weight-bearing exercise?

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