Patient Referral - London Osteoporosis Clinic

For referrals to the London Osteoporosis Clinic please complete the online form below; alternatively you can fax or email a referrals.

Your Name:

Clinic address:

Email:

Phone:

1. Patient Name*

2. Patient Email*

3. Patient Date of Birth*

4. Gender* 

5. Patient Weight (kg)*

6. Patient Height (cm)*

7. Has patient lost any height from peak adult height?*

8. Does patient any symptoms; if so how long?*

9. Any previous Fractures?*

10. Is there is history of parental Hip Fractures?*

11. Does the patient Smoke?*

12. Is Alcohol consumption of 3 or more units/day?*

13. Is the patient taking Glucocorticoids ?*

14. What other medications are they taking?*

15. Does the patient have Rheumatoid Arthritis ?*

16. Does the patient have any medical condition associated with Secondary osteoporosis (such as diabetes, osteogenesis imperfecta in adults, hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, chronic liver disease, inflammatory bowel disease, Coeliac disease, asthma, epilepsy) **

17. Has the patient had a recent DEXA scan – Please forward the results*