Drs. Hill and Thomas Co. Radiology and Medical Imaging

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Osteoporosis Risk Assessment and Physician Order Form

One Out of Two Women Past Menopause Has Osteoporosis

Complete the test below and click Score Test below for results.

1. Are you a woman?	Yes	No

2. Are you thin and/or small framed?	Yes	No

3. Are you fair-skinned and/or do you sunburn easily?	Yes	No

4. Has your mother, grandmother, aunt or sister broken a hip, wrist or lost height?	Yes	No

5. Do you smoke?	Yes	No

6. Do you avoid exercise or going on walks?	Yes	No

7. Do you avoid dairy products and calcium in your diet?	Yes	No

8. (For Women) Have you had your ovaries removed or did you reach menopause before the age of 45?	Yes	No


Your score for risk of low bone mass or osteoporosis:

Discuss the results of the analysis with your physician. If advised, print this page and have him/her sign it and schedule a Dual Energy Absorptiometry (DEXA) test at Drs. Hill & Thomas (check locations). DEXA IS THE METHOD OF CHOICE FOR THE EVALUATION OF OSTEOPOROSIS OF THE HIP AND SPINE AND IS COVERED BY MEDICARE. Please bring this printed page with you to your appointment.

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Signature of Physician

Eastside Imaging Center
2785 S.O.M. Center Rd.
Willoughby Hills, Ohio 44094
(440) 944-8887 or (800) 743-1984

Drs. Hill & Thomas
Ashtabula Medical Arts Center
2131 Lake Avenue
Ashtabula, OH 44004
(440) 998-2222