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Patient information
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Risk Assessment Questionnaire for Bone Densitometry
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Patient Details
First Name
Last Name
Email
Date of Birth
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Booking Details
Do you have an appointment booked with us?
Yes
No
Please select your preferred/booked clinic
Please select...
Barossa
Christies Beach
Glenelg
Modbury Hospital
Mount Gambier Crouch Street North
North Eastern Community Hospital
Salisbury
Branch Email
Appointment Date
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Bone Density Tests
Have you previously had a bone density test?
Yes
No
Test Date and Location
Can the results be obtained?
If possible, please obtain these previous results to bring with you on the day of the scan.
Yes
No
Recent imaging tests
Have you had a Barium/CT or Nuclear Medicine scan in the last week?
Yes
No
Test Date and Scan Completed
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
Which bone(s) and how did you break it?
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
Which bone(s) & when (year)?
Females only
Menopause information
When was your last menstrual period? (Age)
Have you had a hysterectomy?
Yes
No
Age
Have you had your ovaries removed?
Yes
No
Number removed?
1
2
Did you use hormonal therapy (HRT) before the age of 45?
Yes
No
When did this start?