Bone Density Questionnaire

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To display all questions and their answers, this form is designed for landscape mode.

🧑 Patient identity

LAST NAME :

FIRST NAME :

Date of birth :

GP / Referring physician :

Weight (kg) :

Height (m) :

Address :

Home phone * :

Mobile * :

Email * :

* Required: at least one 10-digit phone number and a valid email address.

ℹ️ For men: answer NO to the questions about menopause and HRT.

Menopausal:

YES NO

If yes, at what age:

Hormone replacement therapy (HRT):

YES NO

ℹ️ Important information

Thank you for completing this questionnaire, which will allow us to determine whether your examination falls within the categories covered by health insurance for reimbursement.
Outside the cases covered by the national health insurance, the cost of the examination will be your responsibility.
Please tick the correct answer.

♀ For women — if you are menopausal

Do you have a family history (parent) of hip fracture without major trauma?

YES NO

Did you reach menopause before the age of 40?

YES NO

Are you taking or have you taken corticosteroids for more than 3 months?

YES NO

Is your BMI below 19 kg/m²?

IMC = Poids (kg) / Taille² (m) → —

YES NO

🔄 If this is a follow-up examination

Have you stopped a treatment for osteoporosis?

YES NO

Have you had a bone density examination more than 3 years ago?

YES NO

✍️ Patient declaration

I certify that I have personally completed this form, have read and understood its content, and give my consent for the examination to be carried out.

Full name :

Date of birth :

Date :

Signature :

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CABINET TESLA — MEDICAL IMAGING CENTER

Cognac Clinic • Dr Pierrick MORALES