Osteoporosis Evaluation: SCORE Sheet

Name____________________________________________________________________Date____________________________

23 1. How old are you? {Multiply the number in the shaded area by 3 ( Example 5 x 3= 15 ^{and enter in the space at right 2. What is your race? (Check one.) African-American/Black American If checked, enter 0 at right Caucasian, Hispanic, Asian, Native American/American Indian, If checked, enter 5 at right Other: ______________________________________________________-Check 5 at the right 3. Have you ever been treated for or told you have rheumatoid arthritis? Yes No If Yes, enter 4 at right/If NO, enter 0 at right 4. Since the age of 45, have you experienced a fracture (broken bone) at any of the following sites? Hip Yes No If Yes, enter 4 at right/If NO, enter 0 at right Rib Yes No Yes, enter 4 at right/If NO, enter 0 at right Wrist Yes No Yes, enter 4 at right/If NO, enter 0 at right 5. Are you now taking or have you ever taken hormone replacement therapy (for example: estrogen, Premarin, Estrace, Estraderm, or Estratab)? Yes No If NO, enter 1 at right/If Yes, enter 0 at right Add scores from questions 1-5. 6. How much do you weigh now? (If it is under 100, put 0 in the first box.) {Take the number in the shaded areas {and enter in the space at right, ^{then subtract from the subtotal.

__________ +_________ +_________ +_________ +_________ +_________ +_________ __________ Subtotal - =_________ total score

• If your score is 6 or higher, talk to your doctor about being evaluated further for osteoporosis.

• If your score is less than 6, you should still talk to your doctor about osteoporosis and the risk factors associated with it.

Provided by Edward Loniewski, International Society for Clinical Densitometry (ISCD) Certified. Advanced Orthopedic Specialists. Call 810-299-8550 for appointment

This quiz is not a substitute for your physician’s clinical judgment and consideration of any risk factors you may have.

Trademarin is a registered trademark of Wyeth-Ayerst Laboratories. Estrace is a registered trademark of E.R. Squibb and Sons, Inc. Estraderm is a registered trademark of Ciba-Geigy Corporation. Estratab is a registered trademark of Solvay Pharmaceuticals, Inc.