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Consultation Form

Please use this form to request an appointment

Find out if you are at risk of osteoporosis by completing the questionnaire below.  Please note that osteoporosis is a progressive condition, symptoms only occur if there is a fracture.

Please note this is NOT the definitive list of risk factors for osteoporosis or a substitute for seeing a clinician specialising in osteoporosis; you can directly book now.

Fields marked with * are required.

    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)?

    YesNo

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

    YesNo

    3. Are you 40 years old or older?

    YesNo

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

    YesNo

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

    YesNo

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

    YesNo

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

    YesNo

    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)?

    YesNo

    9. Have you ever been diagnosed with rheumatoid arthritis?

    YesNo

    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 or celiac disease?

    YesNo

    For Woman

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

    YesNo

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

    YesNo

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

    YesNo

    For Men

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

    YesNo

    For Both

    15. Do you regularly drink alcohol in excess of safe drinking limits (more than 2 units a day)?

    YesNo

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

    YesNo

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

    YesNo

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

    YesNo

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

    YesNo

    If you wish to receive an email of your answers to take to your GP then please enter your email address below:

    Your Email

    Your Name

    Your Date of Birth