DEXA QUESTIONNAIRE

Please complete the questionnaire by placing an “X” in the appropriate box, adding details where necessary and signing your consent to have the injection/examination.

Have you had a previous Bone Density (DEXA Study)? YES NO

Have you been diagnosed with Osteoporosis? YES NO

In the last 5 days have you had examinations that involved oral contrast or barium (CT, Nuclear Medicine Scan, or Barium Study)? YES NO

Have you ever had a bone fracture or compression fracture of your spine? YES NO

Do you suffer from Rheumatoid Arthritus? YES NO

Do you suffer from Asthma? YES NO

Are you now or have you ever been on steroids? YES NO

Have you ever had Thyroid, Liver, or Kidney problems? YES NO

Do you suffer from Malabsorbtive Disease ( inflammatory bowel, Coeliac or Crohn’s Disease)? YES NO

Have you recently undergone Chemotherapy? YES NO

Questions below to be answered by Females

Is there any chance that you might be pregnant? YES NO

Have your periods ceased for any length of time? YES NO

Have you reached Menopause? YES NO

How old were you when you reached Menopause? AGE

Have you had a Hysterectomy? YES NO

Are you on hormone replacement therapy? YES NO

I HAVE BEEN MADE AWARE THAT A FEE OF $92.50 WILL APPLY IF THIS EXAMINATION IS NOT ELIGIBLE FOR COVERAGE BY MEDICARE.

Patient Name: __________________________ DOB: ___________________ Signature: _____________________

Please present this completed form at the time of your appointment.