Patient Details

First Name

Last Name

Email

Date of Birth

/

Booking Details

Do you have an appointment booked with us?

Yes

No

Please select your preferred/booked clinic

Branch Email

Appointment Date

/

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

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

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

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?

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

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .GIF, .PNG and .JPG files (less than 5MB) accepted.

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Patient information

Risk Assessment Questionnaire for Bone Densitometry