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DEXA Questionnaire
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DEXA Questionnaire
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*
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This field is for validation purposes and should be left unchanged.
DEXA PRE-APPOINTMENT SCREENING QUESTIONNAIRE
Name
*
Date Of Birth
*
DD slash MM slash YYYY
Phone Number
*
Email
*
PREVIOUS DEXA OR RECENT IMAGING
Have you had a DEXA scan before?
*
No
Yes
Approximate date and location
Have you had any of the following in the last 7 days?
*
CT scan
Nuclear medicine scan
Imaging involving contrast dye
None of the above
Why we ask this:
We ask about previous DEXA scans and recent imaging to help us interpret results accurately, avoid misleading comparisons, and ensure your scan is clinically appropriate.
ORTHOPAEDIC OR SURGICAL HISTORY
Do you have any joint replacements or metal implants?
*
No
Yes
Location(s)
*
Have you had previous spinal or hip surgery?
*
No
Yes
Location(s)
*
Why we ask this:
Metal implants and previous surgery can affect scan accuracy and interpretation.
BONE HEALTH RISK FACTORS
(Please tick any that apply):
Previous fracture after minimal trauma
Family history of osteoporosis or hip fracture
Early menopause (before age 45)
Long-term corticosteroid use
Previous diagnosis of osteopenia or osteoporosis
Why we ask this:
These factors influence fracture risk and help place your results into proper clinical context.
PREGNANCY SCREENING
Are you currently pregnant or possibly pregnant?
*
No
Yes
Unsure
If unsure, date of last menstrual period (if known):
Why we ask this:
DEXA scans use low-dose X-ray radiation. While exposure is minimal, scans are not performed during pregnancy as a precaution.
RELEVANT MEDICAL CONDITIONS AND LIFESTYLE FACTORS
(Please tick any that apply)
Thyroid disease
Rheumatoid arthritis
Coeliac disease
Chronic kidney disease
Conditions affecting nutrient absorption
Regular smoking
Regular alcohol intake (2 or more standard drinks per day)
Why we ask this:
Some medical conditions and lifestyle factors can affect bone health and result interpretation.
MEDICATIONS AND SUPPLEMENTS
Are you currently taking either of the 2 listed supplements?
Calcium
Yes
No
Vitamin D
Yes
No
Are you taking any bone-specific medications (e.g. bisphosphonates)?
Yes
No
Why we ask this:
Medications and supplements can influence bone density measurements.
BODY COMPOSITION CONTEXT
Have you experienced any notable weight change (more than 5kg) in the past 6 months?
No
Yes
Are you currently undertaking regular high-level resistance or athletic training?
No
Yes
Why we ask this:
This information helps interpret muscle and fat measurements where body composition is assessed.
MOBILITY AND POSITIONING
Are you able to lie flat on your back for approximately 10–15 minutes?
No
Yes
Do you experience pain or discomfort lying flat?
No
Yes
Please explain
Why we ask this:
DEXA scans require stillness in a lying position. This helps ensure comfort and safe positioning during your scan.
CONSENT TO SHARE RESULTS WITH YOUR GP
Do you consent to WLC Medical providing a summary of your DEXA results to your treating GP if clinically relevant?
No
Yes
If yes, please provide GP details:
GP name
Clinic name
Email
Phone
Why we ask this:
Sharing results with your GP supports continuity of care and timely follow-up if required.
CONSENT AND DECLARATION
CONSENT
I confirm the information provided is accurate to the best of my knowledge.
I understand that a DEXA scan involves exposure to a very low dose of X-ray radiation.
I consent to undergoing a DEXA scan at WLC Medical.
Signature
Date
DD slash MM slash YYYY
