Osteoporosis Evaluation Sheet
1. What is your current age?
   

2. What is your race or ethnic group?

      African-American/Black American
        Caucasian
        Hispanic
        Asian
        Native American/American Indian
        Other

3.     Have you ever been treated for or told you have rheumatoid arthritis?

        Yes
        No

4. Since the age of 45, have you experienced a fracture (broken bone) at any of the following sites?

    Hip:     Yes     No
    Rib:     Yes     No
    Wrist:  Yes     No

5. Do you currently take or have you ever taken estrogen?
(Examples include Premarin, Estrace, Estraderm, and Estratab.)

    Yes
    No

6. What is your current weight?
    lbs.

Final Score

If your score is 6 or greater, you should be evaluated for further osteoporosis. Talk to your doctor.