Pre Scan Information Form

PLEASE ONLY FILL THIS FORM IN IF YOU HAVE A SCAN BOOKED AT ONE OF OUR CLINICS AND HAVE BEEN INSTRUCTED TO DO SO

Your Details

Name

Phone (when typing, omit gap between your numbers)

Clinic Location & Date of Clinic

Previous DEXA scan T-scores

Please enter two most recent DEXAs if you have had more than one scan

DEXA 1 - Date and Location (Hospital)

DEXA 1 - Femur Neck (Hip) T-score

DEXA 1 - Spine Total T-score

DEXA 2 - Date and Location (Hospital)

DEXA 2 - Femur Neck (Hip) T-score

DEXA 2 - Spine Total T-sore

Supplements

Do you take any of the following supplements?
If so, how much per day?

Calcium (mg)

Vitamin D3 (i.u.)

Magnesium (mg)

Vitamin K2 (mg)

Boron (mg)

Zinc (mg)

Personal Information

Date of Birth

Height

Have you ever had a fragility facture? Yes or No

Do you smoke? Yes or No

Rheumatoid Arthritis? Yes or No

Diabetes? Yes or No

Chronic kidney disease? Yes or No

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

Age of Menopause

Weight

Has either parent ever 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

Crohns/ Coeliac/ Colitis? Yes or No

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

The personal data collected above will be used by Osteoscan UK Ltd for health care purposes, but will also be stored by WIX in the USA. Under Article 6 and Article 9 requirements of fair processing (Article 6(a) and Article 9(2)(a), by ticking this box you are agreeing to the terms & conditions

If you do not agree to the terms and conditions of this form, you will have to fill out your pre-scan information by printing off the forms, filling them out by hand and returning them to either Sarah by email to sarah@osteoscanuk.com at least 4 weeks prior to your appointment, or by bringing them with you to your appointment with Mr Birch.

Please note that if you choose to fill out your forms in this latter way, ie bringing hard copies to your appointment, this will naturally take up time in your consultation as Mr Birch will have to review the information as part of your appointment.

If you are returning paper copies to Sarah, please note you must return them 4-6 weeks prior to your appointment in time for your forms to be uploaded to Mr Birch's clinic portal .

Thanks for submitting!