UDI DEXA Screening Form

UDI DEXA SCREENING FORM
DEXA SCREENING FORM
Name

First NameLast Name
Phone Number
Gender

FemaleMale
Date of Birth
Age
Height
Weight
Emergency Contact
Reason for DEXA scan today?
Please list/describe symptoms you are experiencing (if applicable):
What is your ethnicity? "This information is necessary for the software to analyze your scan**

CaucasianAfrican-AmericanAsianHispanicOther
YES YES
Are you or do you suspect that you are pregnant?

YESNO
Have you had any exam using ingested barium within the past 7 days? If YES, do not continue with this questionnaire. Return all forms to the receptionist and a technologist will speak with you shortly.

YESNO
PATIENT HISTORY
Which hand do you write with?

LEFTRIGHT
Have you had a DEXA (Bone Density) scan in the past?

YESNO
If YES, When
Where?
If YES, please explain.
Type a Have you had prior surgery to your hip(s) or spine?

YESNOOther
Female patients only:
Have you gone through Menopause?

YESNO
If YES, at what age?
Was Menopause started Naturally or Surgically?

NaturalSurgical
Do you have a family history of osteoporosis/osteopenia?

YESNO
Do you currently smoke cigarettes?

YESNO
Do you have a condition known to be associated with bone loss? (e.g. diabetes, absorption disorder, premature menopause, crohn's disease)

YESNO
Do you consume Alcohol?

YESNO3+ Units per Day
Rheumatoid Arthritis?

YESNO
Glucocorticoids?

YESNO
Previous Fracture?

YESNO
Parent Fractured Hip?

YESNO
CURRENT MEDICATIONS
HRT (Hormone Replacement Therapy)?

YESNO
Calcium and/or Vitamin D supplements?

YESNO
Corticosteroids (Steroid Hormones)?

YESNO
Depo Provera?

YESNO
Anticonvulsants (Seizure Medications)?

YESNO
If YES, name of medication?
Thyroid Medications?

YESNO
If YES, name of medication?
Are you currently taking prescription medication for osteoporosis or osteopenia?

YESNO
If YES, how long?
Check all medications that apply:

FosamaxActonelCalcitonin (Miacalcin)BonivaEvistaReclastForteo (PTH)Other
PATIENT SIGNATURE
I attest that the answers I have provided on this form are correct to the best of my knowledge. I have read and understand the contents of this form and have had the opportunity to ask questions regarding the information on this form.
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date
I. HIPAA COMPLIANCE
Name

First NameLast Name (Include Maiden if Applicable)
Date of Birth
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information to only you, your doctor, your insurance and the person(s) listed below. You have the right to revoke this consent, in writing, signed by you. However, such a revocation will not be retroactive.
I authorize the release of my protected health information, including records, results and images to the following person(s) (please check all that apply and include first and last names in the spaces below):

SpouseChild(ren)Other
Spouse's First and Last Name (if authorized above):
Child(ren)'s First and Last Name (if authorized above):
II. OUTSIDE IMAGES/RECORDS RELEASE
PRIOR IMAGES/RECORDS

UDI is committed to providing you and your physician quality care. If you have had relevant imaging done, please complete this portion of the form. Our Radiologists aim to provide a comprehensive analysis for your condition. Please list ALL related prior Imaging Facilities.

ONLY complete the below "Prior Images/Records" portion below if applicable.
Name of the Facility or Hospital where your prior scans were performed
Type of Films
I have read and understand the terms of the I. HIPAA and II. Record Release (if applicable)sections above.
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date
AUTHORIZATION INSURANCE CERTIFICATE FOR PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS
PHYSICIAN INSURANCE ASSIGNMENT
I/we, the below named patient, insurance subscriber and/or legal representative, hereby authorize payment directly to the physicianor group examining or rendering medical/surgical/anesthesia services on my behalf. I understand it is my responsibility to pay any deductibles, patient co-payment amounts. or any other balance not paid by my insurance carrier or third-party payor. I agree to pay the balance due within a reasonable period of time, not to exceed 120 days. If this account is assigned to legal counsel for collection and/ or suit, the group shall be entitled to reasonably attomey's fees and costs of collection.
Insurance Co
ID #
Print name
Date

MonthDayYear
Date
Signature

Clear
Legal guardian
Should be Empty:

UDI DEXA SCREENING FORM

DEXA SCREENING FORM

YES YES

PATIENT HISTORY

Female patients only:

CURRENT MEDICATIONS

PATIENT SIGNATURE

I. HIPAA COMPLIANCE

II. OUTSIDE IMAGES/RECORDS RELEASE

AUTHORIZATION INSURANCE CERTIFICATE FOR PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS

PHYSICIAN INSURANCE ASSIGNMENT