DEXA Consent - Body DEXA Fit

DEXA Questionnaire & Consent Form

The purpose of this form is to determine suitability for a DEXA Body Composition assessment for Dr Janet Macintosh to generate a referral for a DEXA whole body scan in accordance with Victorian State Regulations. Dr Janet Macintosh is a Specialist Medical Practitioner who holds a specialist registration with AHPRA in Radiology. lf you have any questions about the information requested please contact us on 0409647886. All information provided will be kept confidential. Your written permission is required to release any information.

Please note there will be a cost of $40 (Non-Medicare funded) for assessment and referral for DEXA body composition scan.
You will only be charged if you proceed with the initial DEXA scan booking. This initial referral to Body DEXA fit may be used for up to 4 scans within 12 months, to monitor changes in body composition response to intervention, with subsequent scans at least 8 weeks apart.

Alternatively, you may elect to use a Medical Practitioner or specified Allied Health Professional. If using a practitioner other than Janet Macintosh, you need to use this online form instead. n.b. Conditions Apply: A GP or specified Allied Health Professional can only refer if they satisfy 4 prescribed clinical indicators, whereas a Specialist Medical Practitioner such as Dr Janet Macintosh is not subject to those restrictive clinical indicators.

Patient

Name*

Prefix First Last

Date of Birth*

DD

MM

YYYY

BMI

Body Mass Index

Your Occupation*

Email*

Mobile*

Please provide you mobile number.

Address*

Street Address Suburb State Postcode

Weight (Kg)*

Your weight in Kilograms

Height (cm)*

Your height in Centimetres

Health & Lifestyle Goals

What are your health and lifestyle goals for the future, and provide us with any other relevant information

Medical History

Provide details of any current health problems or illnesses or injuries

For example, please let us know if you have back pain or knee injuries

Provide details of past health problems or illnesses or injuries

For example, please let us know if you have back pain or knee injuries

Provide details of any prescription medications

Contraindications

Please note, if you tick yes to any of the 3 below, we will not be able to perform the DEXA scan:

Please check if relevant to your circumstance

Have you had a barium x-ray, nuclear medicine scan or injection of an X-ray dye in the last week?
Is there a chance you may be pregnant?
Have you have undergone 4 DEXA scans in the past 12 months?

DEXA Scan Ineligibility

Unfortunately, due to your particular circumstance, you are ineligible for a DEXA scan for health and safety reasons. We can call you to discuss this. If you would like a follow-up call, please check the box below and we will call you shortly.

Please call me about ineligibility

I would like a call to discuss my ineligibility

DEXA Scan Eligibility

The current regulatory condition to the use of DEXA for assessing body composition requires the scan to be justified and approved by the Radiologist or Radiographer in accordance with written guidelines established by the Radiologist.
We can only provide you a DEXA scan if at least one of the following applies to you - please select the reason(s):

Reason for DEXA Scan*

Body Composition Measurement for sport, including aesthetic, performance or weight category requirements
• To inform lifestyle intervention and set safe body composition targets to improve performance and/or optimise health. Assess fat and lean mass changes including fat mass index (FMI). Visceral fat quantification for cardio-metabolic risk assessment. Reduce risk of developing type 2 diabetes, cardiovascular disease and or mental health disorder. Measurement of Android:Gynoid ratio
Sequential measurements, with subsequent scans at least 8 weeks apart and not more than 4 scans within a year to monitor changes in body composition response to nutrition, activity or lifestyle intervention.
Accurately assess lean and fat mass in overweight individual
• To inform lifestyle intervention and set safe body composition targets to improve performance and/or optimise health. Assess fat and lean mass changes including fat mass index (FMI). Visceral fat quantification for cardio-metabolic risk assessment. Reduce risk of developing type 2 diabetes, cardiovascular disease and or mental health disorder. Measurement of Android:Gynoid ratio
• Sequential measurements, with subsequent scans at least 8 weeks apart and not more than 4 scans within a year to monitor changes in body composition response to nutrition, activity or lifestyle intervention.
Visceral fat quantification for cardio-metabolic risk assessment
• To inform lifestyle intervention and set safe body composition targets to improve performance and/or optimise health. Assess fat and lean mass changes including fat mass index (FMI). Visceral fat quantification for cardio-metabolic risk assessment. Reduce risk of developing type 2 diabetes, cardiovascular disease and or mental health disorder. Measurement of Android:Gynoid ratio
Sequential measurements, with subsequent scans at least 8 weeks apart and not more than 4 scans within a year to monitor changes in body composition response to nutrition, activity or lifestyle intervention.
Assessment of underweight or anorexic individual
• Assess fat and lean mass changes including fat and lean mass indices, in an underweight patient, potential malnutrition.
To inform lifestyle intervention and to set safe body composition targets to work towards healthy weight gain, improve performance and optimise health. Indicative assessment of bone mineral content.
Sequential measurements, with subsequent scans at least 8 weeks apart and not more than 4 scans within a year to monitor changes in body composition response to nutrition, activity or lifestyle intervention.
Suspected/high risk of endocrine disturbance
• Assess fat and lean mass changes including fat and lean mass indices
• To inform lifestyle intervention and set safe body composition targets to improve performance and/or optimise health.
Indicative assessment of bone mineral content.
Limb asymmetry or wasting post-injury or surgery
Assess fat and lean mass changes including fat and lean mass indices.
Segmental lean mass analysis for injury prevention and management.
To inform lifestyle intervention and set safe body composition targets to improve performance and/or optimise health.
Muscle wasting conditions: Cancer, HIV, malabsorption
• To inform lifestyle intervention and to set safe body composition targets to work towards healthy weight gain, improve performance and optimise health.
Indicative assessment of bone mineral content.
Sequential measurements, with subsequent scans at least 8 weeks apart and not more than 4 scans within a year to monitor changes in body composition response to nutrition, activity or lifestyle intervention.

Consent for DEXA Scan*

Agree and Continue

By Checking Agree and Continue, I hereby:
State that the above information is correct to the best of my knowledge.
Provide my personal details and a full medical history so that Dr Janet Macintosh may assess and manage my healthcare and determine suitability for a DEXA Body Composition assessment.
Agree for my medical record to be accessed by staff involved in my clinical care, including Body DEXA Fit for the provision of DEXA Body Composition Assessment.
Accept the additional charge of $40 (Non-Medicare funded) for assessment and referral for DEXA body composition scan. This fee will only be charged if I proceed with the initial DEXA scan booking.

Date*

Supplementary DNA test?

Would you like a DNA Test too?*

Would you like to purchase the DNA test to help you make better health, wellness and lifestyle decisions?

Yes
No

If Yes, please select your preferred DNA Test

$99 myDNA Nutrition , Fitness & Caffeine Test, includes eight-week fitness and meal plan (valued at $198)
$69 myDNA Vitamins Test, understand more about your body’s micronutrient needs

Questionnaire & Consent Form

Step 1 of 2

DEXA Questionnaire & Consent Form

Patient

Medical History

Contraindications

DEXA Scan Ineligibility

DEXA Scan Eligibility

Supplementary DNA test?

CORONAVIRUS PRE-BOOKING CONDITIONS & PROCEDURES

You must complete this page before booking

Please read the following very carefully. They are procedures to minimise the risks to you and our staff and are linked to our Safety Plan.

Please confirm your understanding before making your booking by ticking each box