DEXA Patient Questionnaire

Patient details

First Name *

Last Name *

Mobile number *

Date of Birth *

Date of your booking *

Which centre are you attending? *

Consent for Billing

CT BMD and DEXA scans can only be performed every 1 – 2 years (depending on your medical history) under the regulations of Medicare.

Please inform us if this is not your first CT BMD or DEXA examination. If this claim is rejected by Medicare, you will be responsible for the outstanding account.

Patient Consent

I understand that should liability of this account be denied by Medicare, payment for my examination will become my responsibility.

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Date

Assessment Questionnaire

Are you 70 years of age or older? *

NoYes

If you are female, have you experienced menopause? *

No Yes

If yes, at what age *

DEXA 70 YEARS OR OVER - 12320 (5 YEARS - Initial OR T= greater than -1.5)

Have you ever had a DEXA (Bone Mineral Densitometry) Study? *

NoYes

If Yes, where was the DEXA performed? *

If Yes, was your T-score greater than -1.5? *

NoYesUnsure

DEXA 70 YEARS OR OVER 12322 (24 MONTHS - DEXA or QCT scan with a T-score between -2.4 and -1.5

Have you been diagnosed with Osteopenia on DEXA or CT BMD *

No Yes

DEXA 12306 ( 24 MONTHS PROVEN BMD/FRACTURES )

Have you been diagnosed with Osteoporosis from a DEXA or CT BMD? *

NoYes

Have you had a recent fracture/broken bone following a minor injury? *

NoYes

DEXA 12321 (12 MONTHS - ESTABLISHED LOW BMD - SIGNIFICANT CHANGE TREATMENT)

Are you receiving specific treatment for Osteoporosis? *

NoYes

If Yes, have you had any recent changes to your treatment? (new medication) *

NoYes

DEXA 12312 (12 MONTHS - CLINICALLY INDICATED)

Are you on prolonged steroid therapy treatments (Prednisone or Cortisone)? *

NoYes

Do you have Cushing's Syndrome? *

NoYes

Have you been diagnosed with low testosterone levels? (males only)

NoYes

Have you been diagnosed with low oestrogen levels before the age of 45? (females only)

NoYes

DEXA 12315 (24 MONTHS - CLINICALLY INDICATED)

Do you have any of the following:

1. Conditions associated with excessive Thyroxine levels (HYPERTHYROIDism/ overactive thyroid) *

NoYes

If Yes, is it stable and/or controlled with medication? *

NoYes

2. Chronic Liver Disease? *

NoYes

3. Chronic Kidney Disease? *

NoYes

4. Proven malabsorptive disease by either: *

a. Yes - Malabsorption of fat, confirmed by a faecal fat testb. Yes - Vitamin D deficiencyc. Yes - Histologically / biopsy proven coeliac diseased. None

5. Rheumatoid Arthritis? (This is NOT osteoarthritis. Rheumatoid arthritis is a chronic, autoimmune disease that causes joint inflammation.) *

NoYes

6. Primary HYPERPARATHYROIDism? (Primary hyperparathyroidism is a condition where the PARAthyroid glands become over-active and produce excessive parathyroid hormone (PTH). It can be characterised by excessive calcium levels in the blood) *

NoYes

FRAX Questionnaire

As part of your DEXA examination, we calculate your fracture risk. Certain medical and lifestyle factors affect this risk.

(Please note: some questions may be repeated from previous ones)

A copy of your referral will allow us to assess Medicare eligibility. If you have not already done so, please upload your referral here

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