Self-referral form for a Bone Density DEXA Scan

Self-Referral Form for a DEXA Bone Density Scan

(ie. for a member of public to fill out for themselves, no need for GP/clinician to complete)

Please answer every question. If you are unsure of anything, please contact us to help. The answers to this questionnaire will be kept confidential and are used for the purpose of determining your eligibility for a DEXA bone density scan.


Please complete and return to us by post or via email on or bring with you to your scan appointment.

Please note that due to weight restrictions on the machinery, we are unable to scan any person weighing over 226.6kg. We are unable to perform scans on pregnant people, or those who have had an X-ray examination using contrast dye in the past 7 days.

Patient Information

**We will send a copy of your DEXA scan to your registered GP if your scan results need further investigation.

Please answer the following questions

If you are unsure of anything, please select “Not Sure”

For female patients

All patients – Please confirm if you have ever been diagnosed with any of the following

Please let us know if:

Please add any additional notes you feel may be helpful for your care: (reduced mobility, eyesight, hearing)

For DEXAStrong internal use only