Consent & Questionnaire

Your details

Please provide your contact details so the clinic team can match this form to you.

Full name *

Email address *

Phone number *

Which clinic are you attending? *

Date of appointment *

Time of appointment *

Bone Health Questionnaire

Please complete the form below. This information helps the clinician prepare properly.

Personal Information

Start with the essential information your clinician will need before the scan.

Date of Birth *

Age *

Height (cm) *

Weight (kg) *

Age of menopause (if applicable)

Type of menopause

Do you take HRT? *

YesNo

If yes, please specify HRT

Are you pregnant? *

YesNo

If pregnant, how many weeks?

Dietary preference *

Supplements & Medication

List supplements, prescriptions, and remedies currently being taken.

Do you take oral steroids? *

YesNo

Do you take prescribed bone medication? *

YesNo

If yes, which and timeframe?

Any other prescription medication?

Any herbal remedies? *

YesNo

If yes, please specify herbal remedies

General

A few final details before you continue to consent and payment.

Do you currently smoke or vape? *

YesNo

Do you drink alcohol? *

YesNo

Anything else you'd like us to know before your scan?

Excellence in REMS Scans since 2018

Questionnaire & consent form

Your details

Bone Health Questionnaire

Personal Information

Previous Scan History

Supplements & Medication

Medical History

General

Consent & Questionnaire

Questionnaire & consent form

Your details

Bone Health Questionnaire

Personal Information

Previous Scan History

Supplements & Medication

Medical History

General

Consent & confirmation

Contact

Book A Scan

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