CLMRAD BMD Questionnaire

Patient Name *

Date of Birth *

Height (cms) *

Weight (kgs) *

Email address *

Phone Number *

Have you had any back, hip or femur surgery? *

YesNo

Have you had a bone densitometry before? *

YesNo

When and where was that done? *

What was that result? *

Have you been previously diagnosed with low bone mineral density proven by previous bone densitometry? (Z-score <-1.5 or T-score <-2.5) *

YesNo

Are you taking medications for osteoporosis? (Fosamax, Actonel, Boniva, Didronel, Acalasta, Aredia, Zometa, Bonefos, Prolia, Evenity, Forteo) *

YesNo

Have you had one or more fractures occurring after minimal trauma (as an adult)? *

YesNo

Which bone/s? *

Do you suffer from any of these conditions:

Prolonged glucocorticoid therapy (steroid) *

YesNo

Conditions associated with excess steroid/cortisone secretion (e.g. Cushing’s syndrome). *

YesNo

Hypogonadism (e.g. Turners Syndrome, low testosterone)? *

YesNo

Menopause lasting more than 6 months before the age of 45 *

YesNo

Age of menopause? *

Do you have any of the following conditions:

Hyperparathyroidism (forearm scan required) *

YesNo

Long term liver disease. *

YesNo

Long term renal disease. *

YesNo

Proven malabsorptive disorders (eg Crohns, celiac disease, short bowel). *

YesNo

Rheumatoid arthritis *

YesNo

Rheumatologist Name: *

Conditions associated with thyroxine excess (overactive thyriod). *

YesNo

Has there been any significant change in medication for osteoporosis? *

YesNo

Are you over 70 years of age (1st scan) *

YesNo

Do you currently smoke? *

YesNo

Do you consume alcohol? *

YesNo

If YES, how many standard drinks per day? *

Have either of your parents had a hip fracture? *

YesNo

I acknowledge that if Medicare/DVA rejects my claim, I will be responsible for the outstanding cost of $101.50.

Patient Signature

Draw signature|Type signatureClear

Please wait, files are uploading..

Save and Complete Later

Your progress is saved.

When you're ready to complete your form submission, use this form link:

Copy URL

Office Use

Patient quoted fee $____________Checked other imaging providersScanned previous reports into patient visit

Staff Initials: _________________________ Date:__________________________