Osteoporosis Evaluation Form


1.  What is your current age?
Take the number in shaded area, multiply by 3 and enter

2.  What is your race or ethnic group? 
African-American/Black American, enter 0
Caucasian, Hispanic, Asian, enter 5
Native American/American Indian, enter 5
3.  Have you been treated for or told you have rheumatoid arthritis?
If yes, enter 4
4.  Since the age of 45, have you experienced a fracture (broken bone) at any of the following sites?
Hip - if yes, enter 4
Rib - if yes, enter 4
Wrist - if yes, enter 4

(4 for each, enter up to 12)   

5.  Do you currently take or have you every taken estrogen?
(Examples include Premarin, Estrace, Estraderm, and Estratab)
If no, enter 1
Add score from questions 1-5
6.  What is your current weight?
Take the numbers in shaded area and subtract from subtotal

If your final score is 6 or greater, you should be evaluated further for osteoporosis. Please talk to your doctor.
Used with permission of Merck & Co.