NO o o Have you ever had a DEXA Bone Density Scan before o Have you taken a calcium supplement in the past 24 hours o In the last week have you had an xray or nuclear medicine study that requir ID: 947259
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Crossroads Medical Associates, LLC DEXA Patient Info Form.v6.doc March 2010 DEXA Scan Patient Information Patient Name _____________________________________ Date of Visit: ________________ Date of Birth __________________ Age _____ Physician: ____________________________ NO o o Have you ever had a DEXA Bone Density Scan before? o Have you taken a calcium supplement in the past 24 hours? o In the last week, have you had an x-ray or nuclear medicine study that required barium or contrast? o Have you ever had surgery on the hips or lumbar spine? If so, list: ___________________________________________________ o Have you had a previous fracture? o Has either parent fractured a hip? o Current smoker? o Do you have Rheumatoid Arthritis? o Do you drink more than 3 units of alcohol per day? o Do you take Glucocorticoids? For women only : YES NO o o In the interest of your overall bone health, your doctor recommends that you get the Dexa bone density scan. Nonetheless, some insurance companies do not cover this medical service. Crossroads Medical Associates will make every attem