Click on the appropriate answer:
Do you consume a high proportion of animal protein daily i.e...meat, eggs, and dairy at least two times?	Yes No
Do you take or have you taken any cortisone, blood thinners, anticonvulsant, or antibiotic drugs?	Yes No
Do you drink more than one cup of coffee, tea or other caffinated beverage per day?	Yes No
Do you use carbonated beverages i.e...soda pop, seltzer, etc..?	Yes No
Do you have premature graying of the hair i.e...before age 50?	Yes No
Do you consume more than one alcoholic beverage per day?	Yes No
Do you not take calcium and magnesium supplements daily?	Yes No
Do you drink tap water and/or use toothpaste with fluoride?	Yes No
Do you receive less than one half hour of sunlight daily?	Yes No
Do you eat less than five servings of vegetables per day?	Yes No
Do you consume sweets or white flour products daily?	Yes No
Do you have any family members with osteoporosis?	Yes No
Do you exercise less than two times per week?	Yes No
Do you have a history of being underweight?	Yes No
Do you or have you ever smoked cigarettes?	Yes No
Do you take antacids on a regular basis?	Yes No
Do you have fair skin or sunburn easily?	Yes No
Do you have either blonde or red hair?	Yes No
Do you have thin or petite bones?	Yes No
Do you use salt on your food?	Yes No
Do you have periodontal or gum disease?	Yes No
Do you consider yourself a female?	Yes No
For females: Do you qualify as being post menopausal?	Yes No
Do you not menstruate on a monthly basis?	Yes No

 

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