Osteoporosis affects half of all Caucasian women past age 50. Take steps now to assure your independence and quality of life. Please take a few minutes to complete the following Osteoporosis Risk Survey. Upon reviewing the information you provide, your healthcare provider can advise you regarding your risk of developing osteoporosis and, if necessary, refer you for further testing.

Patient Information:

Your name: _____________________________________________________

Today’s date:_________________________

Address:___________________________________________________________________

City: _______________________________________________________ State: _________

Zip: _______

Age: _______ Age at menopause: __________ Sex: M F Height: __________ Weight:_______

1. Are you a Caucasian or Asian female? Yes No

2. Do you have a family history of osteoporosis? Yes No

3. Do you have a personal history of fracture as an adult? Yes No

4. Did you have surgically-induced menopause or both ovaries removed before age 45? Yes No

5. Do you suffer from irregular or stopped menstrual periods (1 year or more)? Yes No

6. Do you smoke cigarettes? Yes No

7. Do you have low body weight (less than 127 lbs.)? Yes No

8. Have you had a lifelong low calcium intake? Yes No

9. Do you consume more than 2 servings of alcohol daily? Yes No

10. Are you getting little or no weight-bearing exercise? Yes No

1. Are you a woman 65 years of age or older? Yes No

2. Are you a postmenopausal woman under age 65 who has one or more additional

risk factors (from section above) for osteoporosis? Yes No

3. Have you been on hormone replacement therapy for prolonged periods

(more than 3 months)? Yes No

4. Have you taken steroids or glucocorticoid medications (prednisone, cortisone) to

treat asthma, arthritis, lupus or other chronic diseases (3 consecutive months or more)? Yes No