Mayo Medical Centre, Lawn Rd, Castlebar, Co. Mayo
Call Us
094 90 20202
Email Us
info@tmmc.ie
About US
DXA Scan Form – 2026
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
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
Both
Have you had any previous spinal surgery?
(Required)
Yes
No
If yes please specify
(Required)
Medical History
Have you currently or previously had any of the following
Do you have?
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:
Fracture Risk Assessment
Have you broken/fractured any bones as an adult?
(Required)
Yes
No
If yes which bone:
(Required)
Did either of your parents ever break a hip from a fall?
(Required)
Yes
No
Has your family a history of osteoporosis?
(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
I confirm that I have the capacity to provide informed consent and agree to undergo this procedure.
(Required)
Yes
No
I confirm that I understand this DXA scan involves a small amount of ionising radiation (similar to an X-ray). I have read the information provided and consent to undergo the scan.
(Required)
I consent to proceed with the DXA scan as described in the information provided
GDPR CONSENT
(Required)
I consent to the processing of my personal data and medical history for the purposes of this questionnaire.
