Mayo Medical Centre, Lawn Rd, Castlebar, Co. Mayo
Call Us
094 90 20202
Email Us
info@tmmc.ie
About US
DXA – Pre Screening
Pre DXA Screening Questionnaire – Women of Childbearing Age (≤55)
Your DXA scan cannot be performed unless this assessment is fully completed. Please ensure that each question is answered. The scan involves a small amount of radiation. If there is possibility of pregnancy DXA scan is not recommended. Please refer to website for further information on same.
Patient Name
(Required)
Date of Birth
1. Menopause Status
Please indicate which category applies to you:
Premenopausal - Not experiencing any menopausal symptoms and still having menstrual cycles
Perimenopause - Experiencing irregular periods and menopausal symptoms but still having some menstrual cycles
Post menopause - No menstrual periods for 12 months or more
Date of Last Menstrual Period (LMP)
2. Pregnancy Status
Are you currently pregnant?
Yes
No
The scan involves a small amount of radiation. If there is possibility of pregnancy DXA scan is not recommended.
3. Contraception
Are you using any contraception/IUD which stops you having regular periods?
Yes
No
If yes, please specify:
(Required)
Have you had tubal ligation procedure?
Yes
No
4. Breastfeeding
Are you currently breastfeeding?
Yes
No
Patient Declaration
(Required)
I confirm the information provided is accurate.
Date
(Required)
DXA – Pre screening
Pre DXA Screening Questionnaire – Women of Childbearing Age (≤55)
Your DXA scan cannot be performed unless this assessment is fully completed. Please ensure that each question is answered. The scan involves a small amount of radiation. If there is possibility of pregnancy DXA scan is not recommended. Please refer to website for further information on same.
Patient Name
(Required)
Date of Birth
1. Menopause Status
Please indicate which category applies to you:
Premenopausal – Not experiencing any menopausal symptoms and still having menstrual cycles
Perimenopause – Experiencing irregular periods and menopausal symptoms but still having some menstrual cycles
Post menopause – No menstrual periods for 12 months or more
Date of Last Menstrual Period (LMP)
2. Pregnancy Status
Are you currently pregnant?
Yes
No
The scan involves a small amount of radiation. If there is possibility of pregnancy DXA scan is not recommended.
3. Contraception
Are you using any contraception/IUD which stops you having regular periods?
Yes
No
If yes, please specify:
(Required)
Have you had tubal ligation procedure?
Yes
No
4. Breastfeeding
Are you currently breastfeeding?
Yes
No
Patient Declaration
(Required)
I confirm the information provided is accurate.
Date
(Required)
