| 1 |
What is your gender? |
|
Male |
Female |
| 2 |
Do you weigh less than 120 pounds? |
|
Yes |
No |
| 3 |
Do you have weak muscles? |
|
Yes |
No |
| 4 |
Do you worry or feel anxious a lot? |
|
Yes |
No |
| 5 |
In the past year, have you been unhappy more often than happy? |
|
Yes |
No |
| 6 |
Do you use anti-depressants? |
|
Yes |
No |
| 7 |
Do you often use acid-blocking medications called proton pump inhibitors like Prilosec™ or Prevacid™? |
|
Yes |
No |
| 8 |
Do you regularly use, or have you used over long periods of time, products containing steroids like Prednisone or steroidal inhalers? |
|
Yes |
No |
| 9 |
Do you spend an average of 15 minutes per day outside in the sunlight with your arms exposed and without wearing sunscreen? |
|
Yes |
No |
| 10 |
Do you consume at least 5 half cup servings of fruits and vegetables each day? |
|
Yes |
No |
| 11 |
Do you drink more than two servings of alcohol each day? |
|
Yes |
No |
| 12 |
Do you drink more than one serving of soda each day? |
|
Yes |
No |
| 13 |
Do you drink more than two servings of coffee or other caffeinated beverages each day? |
|
Yes |
No |
| 14 |
Are you perimenopausal or menopausal (men, please answer No to this question)? |
|
Yes |
No |
| 15 |
If you answered Yes to question 14, how would you rate your menopause symptoms (e.g., hot flashes, night sweats, vaginal dryness, weight gain, insomnia, etc)? |
Mild |
Moderate |
Severe |
| 16 |
Are you a current smoker? |
|
Yes |
No |
| 17 |
Have you experienced a bone fracture as an adult? |
|
Yes |
No |
| 18 |
Has either of your parents fractured a hip? |
|
Yes |
No |
| 19 |
Have you been told you have "osteopenia" or "osteoporosis" as the result of a bone density test? |
|
Yes |
No |
| 20 |
Do you have on-going bone loss as documented by two or more consecutive bone density tests? |
|
Yes |
No |
| 21 |
Have you lost and regained more than 15 pounds at least three times in your life? |
|
Yes |
No |
| 22 |
Do you exercise less than 30 minutes per day, three days per week? |
|
Yes |
No |
| 23 |
Have you lost half or more of your natural teeth? |
|
Yes |
No |
| 24 |
Have you had three or more major surgeries in your life? |
|
Yes |
No |
| 25 |
Do you have difficulty healing from injuries? |
|
Yes |
No |
| 26 |
Do you suffer from joint pain and swelling? |
|
Yes |
No |
| 27 |
Do you have difficulty falling asleep or staying asleep? |
|
Yes |
No |
| 1 |
Do you take a high-quality, pharmaceutical grade nutritional supplement containing among other things calcium, magnesium, manganese, vitamin D, and vitamin K every day? |
|
Yes |
No |
| 2 |
Do you eat a moderate amount of protein at every meal? |
|
Yes |
No |
| 3 |
Do you eat a variety of fruits and vegetables at two meals each day? |
|
Yes |
No |
| 4 |
Do you include apples, bananas, lemons, limes, or berries in your diet? |
|
Yes |
No |
| 5 |
Do you include asparagus, kale, broccoli, cabbage, yams, or sweet potatoes in your diet? |
|
Yes |
No |
| 6 |
Do you include almonds, pumpkin seeds, or cashews in your diet? |
|
Yes |
No |
| 7 |
Do you drink 8-10 glasses of spring or filtered water per day? |
|
Yes |
No |
| 8 |
Have you completed a detoxification diet in the past 12 months? |
|
Yes |
No |
| 9 |
Do you experience gas, bloating, constipation, diarrhea, or other digestive ailments? |
|
Yes |
No |
| 10 |
Do you engage in weight bearing or strength training exercises at least two times per week? |
|
Yes |
No |
| 11 |
Do you maximize daily exercise by taking short walks, taking the stairs instead of the elevator, etc.? |
|
Yes |
No |
| 12 |
Do you experience "dips" in your energy level during the day? |
|
Yes |
No |
| 13 |
Do you try to minimize stress in your daily life? |
|
Yes |
No |
| 14 |
Do you try to minimize the impact of the things that make you unhappy in life? |
|
Yes |
No |