Download Osteoporosis clinic referral form - Basildon and Thurrock University

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