Pre Scan Information Form
PLEASE ONLY FILL THIS FORM IN IF YOU HAVE A SCAN BOOKED AT ONE OF OUR CLINICS AND HAVE BEEN ASKED TO COMPLETE ONE

Name

Clinic Location & Date of Clinic

DEXA 1 - Date

DEXA1 Femur Neck (Hip) T-Score

DEXA1 Spine Total T-Score

DEXA 2 - Date

DEXA2 Femur Neck (Hip) T-Score

DEXA2 Spine Total T-score

Calcium (mg)

Vitamin D3 (i.u.)

Vitamin K2 (mg)

Boron (mg)

Magnesium (mg)

Zinc (mg)

Date of Birth

Height

Ever had a fragility fracture? Yes or No

Do you smoke? Yes or No

Rheumatoid Arthritis? Yes or No

Diabetes? Yes or No

Chronic kidney disease? Yes or No

Age of Menopause

Weight

Has either parent broken a hip? Yes or No

Do you take oral steroids? Yes or No

Thyroid Problems? Yes or No

Chronic liver disease? Yes or No

Crohn's/Coeliac/Colitis? Yes or No

Do you drink > 3 units per day? Yes or No

Have you ever had a REMS/Osteoscan before? Yes or No

Thanks for submitting!