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*