Please complete this questionnaire in advance of your appointment. The information is very helpful for the doctor who will report your scan. The scan technician may clarify some of your responses on the day. Please provide the requested information as accurately as you can.

Our privacy policy sets out how we manage the information we have collected about you

Bone Density Questionnaire

Please select the correct answer. Provide other information as accurately as possible. Thank you.

First name*

Last name*

Phone*

Email

Date of Birth

Day

Month

Year

Prior diagnosis of Osteoporosis

Yes

No

Rheumatoid Arthritis or SLE

Yes

No

Other Chronic Illness

Yes

No

- please specify

Smoking (current)

Yes

No

Alcohol (3 or more drinks/day)

Yes

No

Any falls in the past. year?

Yes

No

Number of falls:

Hip Replacement(s)

Yes

No

Lower Spine Surgery

Yes

No

We have updated our privacy policy in light of the recent legislative changes.

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