dexa questionnaire 2 - fraser coast radiology€¦ · dexa questionnaire please complete the...
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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.