DXA Scan Form – 2025 | The Mayo Medical Centre

Mayo Medical Centre, Lawn Rd, Castlebar, Co. Mayo

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094 90 20202

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Email Us

info@tmmc.ie

About US

DXA Scan Form – 2025

Patient Name(Required)

Date of Birth(Required)

Mobile Number(Required)

GP Name(Required)

Do you have a medical card or GP visit card?(Required)

Yes

No

If yes please bring your card on the day of your appointment.

Medical/GP Visit Card Number

Expiry Date

Have you had a previous DXA Scan?(Required)

Yes

No

What Year?

Please enter a number from 2000 to 2030.

Where?

Weight (kg)(Required)

Height (cm)

Mobility

Do you require an aid to mobilise?(Required)

Yes

No

If yes specify which:(Required)

Can you get into bed unassisted?(Required)

Yes

No

Have you a history of falls?(Required)

Yes

No

Please list your current medications below:(Required)

Surgery

Have you had any hip replacement(s)?(Required)

Yes

No

If yes please specify:

Left

Right

Have you had any previous spinal surgery?(Required)

Yes

No

Medical History

Have you currently or previously had any of the following

Cancer(Required)

Yes

No

If yes what cancer did you have?

Do you have?

Dementia

Hyperparathyroidism

Coeliac Disease

Crohn’s

Ulcerative Colitis

Eating Disorder

COPD

Asthma

Diabetes

Epilepsy

Multiple Sclerosis

Parkinsons Disease

Stroke

Have you any other conditions we should be aware of:

Please bring a list of your current medications to your appointment

Have you ever taken any of the following medications:

Forsteo Injection – Daily

Fosamax/Fosavnce (Alendronate) – Weekly Medication

Bonviva (Ibandronic Acid) – Monthly Medication

Prolia – Six monthly Injection

Aclasta Infusion (Zoledronic Acid)

Calcium

Vitamin D

HRT

Epilim (Valproate)

Eltroxin

Neo-Mercazole

Steroids (longer than 3 months)

Has your family a history of osteoporosis?(Required)

Yes

No

Fracture Risk Assessment

Have you broken any bones?(Required)

Yes

No

If yes which bone:

Did either of your parents have broken hip?(Required)

Yes

No

Have you ever taken steroids (for 3 months or more)?(Required)

Yes

No

Do you have Rheumatoid Arthritis (diagnosed by a Rheumatologist)?(Required)

Yes

No

Do you drink 3 or more alcoholic drinks per day?(Required)

Yes

No

Are you a current smoker?(Required)

Yes

No

Consent

Have you full capacity to consent to this procedure?(Required)

Yes

No

This is essential as there is ionising radiation emitted (similar to x-ray) which you must be aware of and consent to.

I declare that all information is true and accurate(Required)

I declare that all information is true and accurate

(Required)

I consent to proceed with the DXA scan as described in the information provided

GDPR CONSENT(Required)

I give my consent for my personal data and medical history to be used in this questionnaire

Mayo Medical Centre

Mon – 8-5.30pm
Tues – 8-7pm
Weds – 8-7pm
Thurs – 8-5pm
Fri – 8-7pm

Contact

094 90 20202
info@tmmc.ie
Mayo Medical Centre
Lawn Rd, Castlebar, Co. Mayo
Fax : 094 90 38677