DXA Report

Welcome!

This formulary was build to help you to make DXA structured reports.

The template follows the International Society for Clinical Densitometry (ISCD) positions: ISCD

For children, adolescents, premenopausal women and men age less than 50, choose the Z-score formulary.

Clinical Data:

Name:

Gender

Female

Male

Birth Date:

Exam Date:

Indication:

Referring Physician:

Lumbar Spine:

Z-score Lumbar

BMD Lumbar

Lumbar Levels

Hip:

Side:

Left

Right

Z-score Femoral Neck:

BMD Femoral NecK:

Z-score Total Hip:

BMD Total Hip:

Coments:

Statement regarding technical quality,artifacts,and reason(s) for exclusion of vertebral bodies and/or other skeletal sites.:

Technical Quality:

Densitometer

Prior Exam:

Has prior study to compare?

Yes

No

Prior Exame Date

Prior Lumbar Spine BMD

Prior Femoral Neck BMD

Prior Total Hip BMD

Report:

Dual-Energy X-ray Absorptiometry (DXA) Report

Clinical History:

Referring Physician:

Indication:

Results:

LUMBAR SPINE :

FEMUR :

Technical Quality and Coments:

IMPRESSION:

Based on BMD diagnosis is consistent with (WHO criteria)

Prior exam:

Fracture Risk:

To evaluate fracture risk in patients in accordance with the ISCD/NOF recommendations, visit FRAX site.: FRAX

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