DEXA Body Composition
Request Form	

Name:  <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:Postcode>>  <<Patient Demographics:State>>	
Phone Number:  (m) <<Patient Demographics:Phone (Mobile)>>  (h) <<Patient Demographics:Phone (Home)>>  Medicare No. <<Patient Demographics:Medicare Number>>	

Purpose of scan for this patient/client:	

	 Assess fat and lean mass changes in a person who is following a diet and exercise program where a	
	 whole-body composition scan may provide the information required to tailor their program to ensure they maintain 	
	 healthy levels of body fat, avoid muscle wastage, remain healthy, preventinjury, predict cardiometabolic risk; or	
		
	 Sports Performance: This person is involved in sport where a whole-body composition scan will provide them with 	
	 relevant information to allow them to change their training and dietary needs to ensure they maintain healthy	
	 levels of body fat, remain at good physical condition and prevent injury; or 	
		
	 Assess fat and lean mass changes in an obese patient who has undergone bariatric surgery; or	
		
	 Clinically manage a patient with true muscle weakness or poor physical functioning due to injury or medical 	
	 condition (e.g sarcopenia) where the impact on clinical outcomes I uncertain; or 	
		
	 Assess fat distribution in a patient undergoing anti-retroviral therapy associated with a risk of lipoatrophy 	

Comments: 

Referrer name:  <<Doctor:Name>>	Provider No: <<Doctor:Provider Number>>	
Referrer email or Phone No :  <<Practice/Location:Phone>>	<<Practice/Location:E-mail>>  Date:  <<Miscellaneous:Date>>	

Qualification of referrer.

x	 Medical Practitioner		 Physiotherapist		 Accredited Exercise Physiologist	
						
	 Accredited Practising Dietitian				 Accredited Sports Dietician	
						
	 Accredited Personal Trainer (min Cert IV)				 Accredited Sports Scientist	

	 I confirm that I am managing the patient/client and that the diagnostic information is required for their 	
	 ongoing management.	

reception@tasmaniaimaging.com.au www.tasmaniaimaging.com.au 
	1/64 York Street, Launceston, 7250 
Ph: 03 6364 3866