Osteoporosis Screening Form
This Osteoporosis Screening Form is a quick way to assess your bone future and possible risk of fracture
Select all the appropriate answers, then click the submit button only once. You must have your javascript on.
Your Name
:
Non Modifiable Risks
No
Yes
Are you female?
Are you Asian?
Are you Caucasian or have a fair complection?
Do you have a small boned frame?
Are you 40 - 49 yrs old?
Are you 70 years old or older?
Do you have a family history of osteoporosis?
Have relatives lost height as they aged?
Have any of your relatives had a wrist, vertebral, or hip fracture?
Modifiable Risks
( Behavioral/Lifestyle/Diet, Medical conditions, Medications)
No
Yes
Do you smoke cigarettes, 1 - 10
( ½ pack )
a day?
½ pack - one pack a day?
more than a pack a day?
Do You drink alcoholic beverages?
( 2 oz liquor = one mixed drink = one glass of wine = one 12 oz beer )
Up to 2 oz or one beer a week? 2
2 - 12 oz day or two - six beers a week?
One mixed drink or beer a day or more? 7 drinks a week or more.
Are you a vegetarian or have a diet heavily weighted to vegetables?
Is your diet high in red meat or animal protein?
Do you consume less than one portion of dairy products a day?
Do you drink 3 or more cups of coffee or caffeinated beverages like soda / tea a day?
Do you exercise infrequently or not at all?
PATIENT & MEDICATION HISTORY
No
Yes
Have you had a fracture? Any fracture wrist, spine or hip?
Do you have an eating disorder like Anorexia or Bulemia?
Do you have hyperthyroidism?
Do you have hyper para thyroidism?
Do you have inflammatory bowl disease like Chron’s Disease or Ulcerative Colitis?
Do you have inflammatory arthritis like Rheumatoid arthritis or Gout?
Do you have Diabetes?
Have you had your stomach removed?
( a gastrectomy )
Do you have biliary cirrhosis?
Do you have kidney disease?
Do you have Asthma that requires any steroids, even inhaled steroids?
FOR WOMEN ONLY
No
Yes
Are you menopausal?
Have you had your ovaries removed
(Oopherectomy before age 46)
?
Have you ever missed a period or had amenorrhea?
Have you breast fed at least one child?
Have you not given birth to a child?
MEDICATION
No
Yes
Do you take or have you ever taken: Prednisone?
For up to a cumulative total of six months during your life time?
Commutative total of up to one year during your life time?
Commutative total of one to five years during your life time?
More than 5 years during your life time?
Have you ever taken Lupron or GNRH agonists?
Do you take thyroid medication?
Have you ever received chemothearpy
Have you ever used anti-convulsants like dilantin?
Have you ever taken diuretics like Lasix?
Have you ever used Lithium?
Have you ever taken Heparin?
Assessing Your Osteoporosis Risk
0 to 15
Low Risk
information
16 to 29
Moderate Risk
information
30 to 75
High Risk
information
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