GDPR CONSENT(Required) I give my consent for my personal data and medical files to be used in this questionnaire.Patient Name(Required) Date of Birth(Required) DD slash MM slash YYYY Mobile Number(Required)Email address(Required) Have you had a scan here before?(Required) Yes No What Year?Do you have a Medical Card?(Required) Yes No Medical Card Number GP Name Consultant’s name Have you sustained a fracture as an adult?(Required) Yes No Which part of the body did you break? (identify Left or right side) Do you have a hip replacement?(Required) Yes No Do you take? steroids calcium vitamin D bone medication bone injections Do you have? coeliac COPD diabetes hyperthyroidism (overactive thyroid) hypothyroidism (underactive thyroid) epilepsy rheumatoid arthritis List medications (taken for above conditions) Did you have early menopause?(Required) Yes No What age were you Do you have a history of cancer yourself, not your family?(Required) Yes No If yes what cancer did you have?Has your family a history of osteoporosis?(Required) Yes No Are you fully mobile and independent to proceed with the DEXA scan?(Required) Yes No The scanner is like a bed that you have to independently get up onto, during the DEXA scan you have to hold position for a period, then change position left and rightWOMEN ONLYAre you postmenopausal Yes Are you premenopausal Yes Are you pregnant Yes No Date of last menstrual period DD slash MM slash YYYY We advise patients there is a very small amount of radiation during the DEXA scan and would not recommend if there is any doubt of pregnancy. COVIDAre you fully vaccinated?(Required) Yes No Please inform us if you develop any Covid symptoms before your appointment. Consent(Required) I declare that all the information above is true and accurate to the best of my ability. Δ
