DEXA Scan Patient Information

Patient Name _______________________________________ Date of Visit: ________________

Date of Birth __________________ Age _____ Physician: ______________________

Height _____ft _____in Weight _______lb Ethnic Background_________________ Gender: › M › F

YES	NO
›	›	Do you have a previous history of osteoporosis or osteopenia?
›	›	Have you fractured any bones? If so, which bone & when:____________________________________________
›	›	Have you had any height loss? If so, how much? ____________
›	›	Are you taking calcium supplements? If so, how many milligrams per day?
›	›	Have you ever taken Corticosteroids or Prednisone? If so, over what period: _____________________________
›	›	Have you taken a calcium supplement in the past 34 hours?
›	›	In the last week, have you had an x-ray or nuclear medicine study that required barium or contrast?
›	›	Have you ever had surgery on the hips or lumbar spine? If so, list:_____________________________________

Circle any of the following conditions that you have had in the past:

Asthma	Cancer of the Breast	Cancer of the Uterus	Diabetes
Lupus	Rheumatoid Arthritis	Thyroid Problems	Osteo Arthritis
Chronic Renal Failure	Anorexia	Bulimia	Hyperparathyroid

Circle any of the following medications that you are presently taking:

Fosamax

Evista

Actonel

Miacalcin

For women only:

›	›	Do you have regular periods?
›	›	Are you post-menopausal? If yes, age of menopause: _____________
›	›	Have you had a hysterectomy? If so, date: ________ Number of Ovaries: ______
›	›	Have you had any height loss? If so, how much? ____________
›	›	Is there any chance you could be pregnant? Date of last period: ________________

Waiver of Liability

Crossroads Medical Associates will make every attempt to have the DEXA scan reimbursed by your insurance company. In the event that the DEXA scan is considered routine or otherwise not payable by your insurance company, we will bill the patient for the DEXA scan. By signing this form, the patient or responsible party agrees to pay Crossroads Medical Associates for the DEXA scan in the event that the insurance company refuses payment.

Patient / Responsible Party Signature____________________________ Date _____________