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* MaleFemale5. 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?* YesNo12. Is Alcohol consumption of 3 or more units/day?* YesNo13. Is the patient taking Glucocorticoids ?* YesNo14. 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*