About Our doctors News Careers Online imaging (Benson Connect) Contact

Patient Information
Referrer Information
Our Imaging Services
- Types of Imaging
- Specialised Services
Find a Clinic
Book Now

Book Now
About
News
Patient information
Referrer information
Our imaging services
Find a clinic
Contact
Careers
Online imaging (Benson Connect)
Privacy

Patient information

Patient information
Online Booking
Upload your referral
Information about your scan
Before your appointment
Non attendance
Patient rights
Billing policy
Your feedback
MRI safety

Risk Assessment Questionnaire for Bone Densitometry

Patient Details

Full Name

First Name *

Last Name *

Email *

Date of Birth *

Date *

Booking Details

Do you have an appointment booked with us? *

Yes

No

Please select your preferred/booked clinic *

Date your appointment is booked *

Date *

Branch Email

Bone Density Tests

Have you previously had a bone density test? *

Yes

No

Test Date and Location *

Do you have access to your previous BMD results from another provider? *

Yes

No

Previous BMD results *

Do you consent to Benson Radiology obtaining a copy of your previous bone density results? *

Yes

No

Please complete our consent to release medical information and previous imaging form.

Consent to release medical information and previous imaging

I have completed the patient consent form *

I have completed the patient consent form

Recent Imaging Tests

Have you had a Barium/CT or Nuclear Medicine scan in the last week? *

Yes

No

Select your current therapy(s) for bones *

None

Calcium

Vitamin D

Bisphosphonate

Prolia

Other

Current Bone Therapy (Other) *

Have any of these treatments started in the last year? *

Yes

No

Fracture History

Have either of your parents had a hip fracture? *

Yes

No

Have you ever broken/fractured any bones as an adult from minimal trauma? *

Yes

No

Conditions

Tick any conditions you have in this list

Overactive Thyroid (e.g. Graves disease)

Overactive Parathyroid

Long term Kidney disease

Long term Liver disease

Rheumatoid arthritis

Type 1 Diabetes

Long term steroid therapy or inhaled steroids/puffers (e.g. Prednisolone, Seretide/symbicort)

Bowel conditions associated with malabsorption of fat or low Vit D

Histologically proven Coeliac/Crohns Disease

Male hypogonadism or anti-androgen therapy

None

Do you currently smoke? *

Yes

No

Do you consume more than 3 standard drinks of alcohol a day? *

Yes

No

Bone surgery

Have you had any operations on your Spine or Hip (including replacements)? *

Yes

No

Females Only

Menopause information

When was your last menstrual period? (Age)

Have you had a hysterectomy?

Yes

No

Have you had your ovaries removed?

Yes

No

Did you use hormonal therapy (HRT) before the age of 45?

Yes

No

Upload Documents

To assist us with your appointment, please upload photos/scans of any relevant information such as your request form (if you have one) or implant card

Have we already received a copy of your request form? *

Yes

No / Unsure

Do you have a copy of your request form? *

Yes

No

Upload Document *

Staff Member Name Consenting Patient

Leave this field blank