DEXA scan Colchester

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GP name / Doctor's name:

Surgery name:

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First body area:

How long have you been complaining of symptoms in first body area?:

(period)

What symptoms do you have in the first body area?

Difficulty in moving

Dull ache

Feeling generally unwell

Headache

Limitation of movement

Limping

Numbness

Pain - sharp

Pins and Needles

Stiffness

Swelling

Weakness

None of them

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Second body area scan:

Second body area symptoms:

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Third part body area scan

Third body area symptoms

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Fourth part body area scan

Fourth part body area symptoms

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Referral letter

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Please upload here the referral letter file:

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Please note the referral letter should:

be issued by a registered GP, Doctor, Consultant, Specialist, Physiotherapist or Osteopath;

contain the patient’s full name and date of birth;

specify the indications or symptoms, the type of scan requested and the body area(s) to be scanned;
be signed and show the GMC or other registered number of the referring party.

Other medical information

Please answer the questions below:

Have you had any surgery in the last 8 weeks?

Do you have a cardiac pacemaker?

Do you have any metal implants or prostheses?

Do you have any metal fragments in the eye?

Are you pregnant?

Are you breast feeding?

Do you suffer from claustrophobia?

Do you have an aneurism clip?

None of them

Do you have any of the following:

Allergies

Asthma

Depression

Diabetes

Epilepsy

Heart disease

High blood pressure

Do you have a cochlear implant or neurotransmitter?

Do you have a programmable ventriculoperitoneal shunt?

Do you have kidney/renal impairment?

None of them

Have you seen a GP or Consultant regarding this problem?

Yes

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Are you in good general health?:

Yes

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Have you had any injuries or accidents?:

Yes

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Have you had any operations or scans?:

Yes

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Are you taking any medication or tablets?:

Yes

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Please provide some additional information, so our medical team can provide a referral for your scan:

Thank you for your payment.

Please provide some additional information, and upload your referral letter:

Referral letter

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