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Osteoporosis Service, Rheumatology, Directorate of Medicine Emergency Care Osteoporosis Clinic Referral - Request for DXA (hip & spine) scan Send to Osteoporosis Clinic, Room 2420, Level D, Basildon Hospital Or Fax – 01268 394975/ Post Courier 33 Contact: Phone– 01268 524900 x 8905 PATIENT DETAILS NAME: (please print) ADDRESS: DATE OF BIRTH: HOSPITAL No: NHS No: TELEPHONE No: INDICATION FOR HIP & SPINE DENSITOMETRY (DXA) First DXA - Diagnosis of Osteoporosis or assessment of fracture risk Repeat DXA – Monitor efficacy of treatment or change in bone density. What was the date of the last DXA scan?............................... Please attach the results of any previous bone density scans NOT performed at Basildon Hospital. GUIDELINES RECOMMENDS THAT THE PATIENTS MUST HAVE AT LEAST ONE INDICATION FOR DXA LOW TRAUMA FRACTURE Date of RADIOLOGICAL OSTEOPENIA fracture Please attach a copy of the x-ray report. Neck of Femur ABNORMAL HORMONAL STATUS (please tick) Forearm Vertebral Untreated premature menopause aged ≤45yrs Other (please state) History of prolonged amenorrhoea (pre-menopause) Guidelines support the treatment of patients aged 75+ with a low trauma fracture without DXA unless clinically indicated Testosterone deficiency DRUG INDUCED RISK (please tick) OTHER RISK FACTORS (please tick) Glucocorticoids – aged ≥65+ with exposure to oral steroids for ≥3 months Anorexia Nervosa Chronic Liver Disease Chronic Kidney Disease Hormone Antagonists for breast cancer Hormone Antagonists for prostate cancer CKD stage 4/5 with fracture, ensure optimal bone profile* Coeliac Disease High Falls risk Hyperparathyroidism Anticonvulsants Anti-psychotics Long-term heparin ≥3 months Depo-Provera ≥2yrs FRAX RISK ASSESSMENT If you assessed the patient using FRAX enter the results Inflammatory bowel disease Parental history of hip fracture Rheumatoid Arthritis Vitamin D deficiency …………..% risk of hip fracture Other (as per local guidelines) …………………………………….. ……………% risk of major osteoporotic fracture ADDITIONAL SUPPORTING INFORMATION (including smoking & alcohol history) Does the patient need transport? YES Referring Doctor Signature NO PATIENT REQUIREMENTS Does the patient require hoisting:YES NO REFERRER DETAILS Contact Details Date Does the patient require oxygen? YES NO *CKD stage 4/5 with fragility fractures- PTH-CKD stage 4-2-3 times normal (14-21 pmol/l); Dialysis- 2-9 times normal (14-63 pmol/l); PhosphatePredialysis- 1.1-1.5mmol/L; Dialysis- 1.1-1.7mmol/L; Calcium- 2.2-2.6 mmol/L; Vitamin D >50 nmol/l