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Tell us your Osteoporosis Story
First Name:
Zip Code:
Age Range:
21-45
46-64
65 or older
Have you been diagnosed with osteoporosis?
Yes
No
No, but immediate family members have been.
How did you first learn about osteoporosis?
Doctor, nurse or health clinic
advertisement
newpaper article
health fair or community event
famiily or friend
Other
Have you had a bone density test?
Yes
No
If
Yes
, which type of test was performed?
Heel
Arm
Hand
How was is paid for?
Insurance
Self paid
Free
If
No
, why not?
No Insurance
insurance does not cover
doctor did not order
Have you ever had a fracture related to osteoporosis?
Yes
No
How are you being treated? - check all that apply
diet guidelines
calcium supplements
exercise
hormone replacement therapy
other perscription medicine
alternative treatments
How does osteoporosis affect your personal life?
Arizona Public Health Association
/
Arizona Department of Health Services
/
Bone Builders
/
National Osteoporosis Foundation
/
National Women's Health Information Center
© 2002 Arizona Osteoporosis Coalition.
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