CONSENT FORM: DEXA SCAN AND/OR METABOLIC RATE TESTING
Thank you for reviewing the information below in regards to testing for your DEXA scan and/or Resting Metabolic Rate (RMR) test, and signing this form (see the bottom of the page).
Best wishes,
Omar Sultan Haque, M.D., Ph.D.
Medical Director
1101 Beacon Street, Suite 8-West
Brookline, MA 02446
617-651-2528 (phone)
844-733-6150 (fax)
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I hereby consent to engage voluntarily in DEXA (Dual Energy X-Ray Absorptiometry) scan testing and/or Resting Metabolic Rate (RMR) testing at 1101 Beacon Street, Suite 8W, Brookline, MA 02446. I understand the following information and agree to its guidelines described below:
WHY GET A DEXA SCAN?
-A DEXA scan is a radiological test that uses X-rays to measure the amount of X-rays absorbed by different tissues in the body, and can thereby create an image of one’s body and measure body composition.
-Testing is an appropriate tool for:
-Measurement beyond the limitations of Body Mass Index (BMI)
-Measurement beyond the limitations of the scale (absolute weight amount).
-Determination of body composition, specifically, amount of visceral adipose tissue (VAT), and percent muscle vs. adipose tissue.
-Determination of bone mineral density, osteoporosis risk/progression/monitoring, and fracture risk.
-Helping to inform clinical treatment planning in light of the above information to optimize health, wellness, longevity, and minimize cardiovascular disease risks and mortality.
-Baseline measurement, and future tracking of progress in a medically supervised weight loss program
TEST INFORMATION
-The entire appointment time is approximately 25 minutes, for setup and debriefing.
-The test is performed by lying down on top of the DEXA scan table while the arm of the DEXA machine scans the body, which takes approximately 7 minutes to complete.
-Do your best to get into a comfortable position when lying down on your back, and relax as much as possible, but try your best to not move. Also try your best not to fall asleep, in case your clinician has further instructions for you during the test (e.g., adjusting your limbs to be fully in the scanning zone, etc.)
-You should not talk during the test unless you are experiencing problems.
-You may discontinue the test at any time and for any reason.
After about 7 minutes the device scanning arm will stop moving, indicating the test is finished.
-You should remain on the scanning table until the clinician indicates it is time to leave the scanning table. Sometimes a scan needs to be repeated if there was a lot of movement.
-When instructed, you should slide your legs off to the side of the table, and then sit up, and then stand up from sitting. If you feel dehydrated or are on any medications that may make you dizzy, please sit up and stand slowly.
PREPARATION
To prepare for your DEXA scan, please do the following to optimize the accuracy of your results:
-Avoid any calcium supplements on the day of your exam
-Prior to your scan, we recommend you remove all metal objects that may attenuate/bias/scatter the image (i.e. jewelry, belts/buckles, and shoes).
-Avoid wearing a belt on the day of your scan or remove your belt before the scan. Metal in the belt, as well as the squeezing effect of the belt, can bias your results.
-It is recommended, but not required, for you to wear loose fitting clothing during your DEXA scan. Avoid wearing a tight waistband, and/or very tight and/or restrictive clothing (like spandex or spanx). Ideal clothing is sweatpants and a casual shirt/sweater.
HEALTH RISKS: GENERAL
-This test is painless, and should be painless
-There are no restrictions on your movement, driving, or activities after the test
-You should NOT get a DEXA scan if you have had radiographic contrast (IV or oral) in the last 6 days (i.e. during a MRI or CT scan) or a barium exam (e.g. swallowing test).
-This test uses X-rays, and includes exposure to X-ray radiation. The amount of radiation exposure in a single DEXA scan session is 4.7 µSv, which is comparable to the background radiation from the sun that is received by a person over a normal day.
In comparison, here are average radiation exposures for different situations:
One DEXA Scan 4.7 µSv
Natural daily background radiation 6.6 µSv
One week of a ski vacation 15.0 µSv
One Chest x-ray 50.0 µSv
One Round trip transcontinental flight 60.0 µSv
One Mammogram 450.0 µSv
One Lateral lumbar spine x-ray 700.0 µSv
Natural annual background radiation 2400.0 µSv
HEALTH RISKS: PREGNANCY
-It is your responsibility to tell your clinician or technician performing the DEXA scan if you are pregnant or think you may be pregnant.
-If you are pregnant at the time of your DEXA scan, you would be exposing your unborn but still developing fetus/baby to potentially harmful X-ray radiation.
-You should NOT undertake this test if there is a chance you are pregnant, specifically, you should NOT have a DEXA scan if you are a premenopausal female who is sexually active and is not regularly using a reliable form of birth control.
-If you are a premenopausal female and have been sexually active in the last month and have not been regularly using a reliable form of birth control, it is recommended that you get a pregnancy test before undertaking this DEXA scan.
RESTING METABOLIC RATE (RMR) TESTING:
-This test, called indirect calorimetry, determines your metabolic rate by measuring the amount of oxygen used (VO2), and carbon dioxide released (VCO2) by your body. Specifically, your Resting Metabolic Rate (RMR) is measured, which is the number of calories that your body needs to maintain basic bodily functions, such as breathing, blood circulation, digestion and other processes while at rest and not engaging in any type of exercises.
-Resting Metabolic Testing is an appropriate tool for:
Determination of a patient Resting Metabolic Rate
Helping identify whether one’s metabolic rate is slow, normal, or fast, compared to others
Determination of the precise caloric intake required for weight loss or maintenance
Helping someone break weight plateaus
-The test is performed by breathing through a disposable mouthpiece that is connected to Resting Metabolic Rate equipment. A nose clip is used to assure that all air passes through the mouthpiece.
-You will continue to breathe through the mouthpiece for about 10 minutes.
-This test should be painless and requires minimal preparation.
-To the best of our knowledge, there are no known major or acute health risks associated with this evaluation. During the test, you should breathe normally; neither faster nor slower than you normally breathe.
-The test’s accuracy depends on the factors that have been explained in the communications I received before my test:
Before the Test
To make the test as accurate as possible, we recommend the following preparation:
1. Avoid eating anything for at least 8 hours before the test.
2. Do not engage in any strenuous exercise the day before the test and avoid physical activity as much as possible on the day of the test.
3. Dress comfortably in loose fitting clothing.
4. For at least 12 hours before the test: avoid stimulants such as caffeine or cold medications or nicotine. Prescription medications should be taken according to schedule.
During and after the Test
1. During the test, you will sit on a comfortable couch. It will be important to get into a comfortable position and relax as much as possible, but not fall asleep.
2. A nose clip will be placed on your nose.
3. You will be given a mouthpiece to breathe in. You will be breathing in fresh air from the room, but the gas that you breathe out will go through a tube into the metabolic analyzer to measure your metabolic rate.
4. You should make a tight seal with your lips around the mouthpiece to ensure that all the air you exhale will be analyzed.
5. You should not talk during the test unless you are experiencing problems.
6. After about 10 minutes the device will beep, indicating it is finished.
7. You may discontinue the test at any time and for any reason.
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***Our specialized tests are not covered by insurance, and no insurance claims should be filed by us, you, or any third party, and no out of network benefits apply to the services for DEXA and/or RMR at our clinic***
ELECTRONIC SIGNATURE
With my electronic signature below, I indicate that I have read this form, and I understand the test(s) procedures, possible benefits, and possible risks that I will undertake, and all information described above, and agree to this form’s content and guidelines, and consent to undertake a DEXA scan and/or Resting Metabolic Rate (RMR) testing at 1101 Beacon Street, Suite 8W, Brookline, MA 02446. If I have any questions or clarifications, I will ask them to my clinician before my test and/or to the staff performing my test. Knowing the test’s process, nature, possible benefits and possible risks, I consent to participate.