Osteoporosis Evaluation

Answer these questions to the best of your ability to determine if you are at risk for osteoporosis. This is a confidential test. You will not be contacted regarding the results of this test; however, we urge you to share your results with your doctor.

1. How old are you?
   
   
2. What is your race? (Choose one)
   African American/Black American
   Caucasian
   Hispanic
   Other
   
   
3. Have you ever been treated for or told you have rheumatoid arthritis?
   Yes
   No
   
   
4. Since the age of 45, have you ever experienced a fracture (broken bone) at any of the following sites?
   Hip     Yes No
   Rib     Yes No
   Wrist Yes No
   
   
5. Are you now taking or have you ever taken hormone replacement therapy (for example: estrogen, Premarin, Estrace, Estraderm, or Estratab)?
   Yes
   No
   
   
6. How much do you weigh now? (If under 100 pounds, enter 0)
   Lbs.
   
   
7. What is your zip code? (Optional)