Patient Name:

Medical Record Number:
Date of birth:

Patient phone number:

PROCEDURE(S) REQUESTED :

DEXA BONE DENSITOMETRY

DEXA BODY COMPOSITION ANALYSIS

DIABETIC RETINAL IMAGING (FUNDUS PHOTOGRAPHY)

24 – HOUR AMBULATORY BLOOD PRESSURE MONITORING

CONTINUOUS GLUCOSE MONITORING SYSTEM

THYROID ULTRASOUND

THYROID ULTRASOUND W/ BIOPSY (Please Note: Endocrinology consultation required)

CAROTID INTIMAL-MEDIAL THICKNESS ANALYSIS

NERVE CONDUCTION MEASUREMENT

        Median / Ulnar L R

        Peroneal / Tibial L R

Clinical Indication For Study:

 DEXA - ABSOLUTE CONTRAINDICATIONS: PREGNANCY , NUCLEAR MEDICINE/CONTRAST STUDY WITHIN PAST 7 DAYS.

 

CLINICAL HISTORY & MEDICINES: Ambulatory Wheelchair

PLEASE CHECK if patient is taking any of the following:

Estrogen     Evista     Fosamax     Actonel     Miacalcin

Blood Pressure Medicine     Thyroxine     Diuretics     

Steroids: Oral     Inhaled

 

REFERRING PHYSICIAN : _ Pager #:

Phone #: Fax #:

 

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