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). It explains the tests, preparation, possible benefits, risks and limitations.

Best wishes,

-DEXA Scan Boston

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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:

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1.  Understanding your tests

DXA body composition scan

DXA, also called DEXA, stands for dual-energy X-ray absorptiometry. It uses low-dose X-rays to estimate body fat, lean tissue and bone mineral measurements. Results may include total and regional body fat, lean tissue distribution and estimated visceral fat around abdominal organs. These measurements can establish a baseline and help track changes during fitness, nutrition or weight management programs.

Lean tissue includes muscle, body water and other non-fat soft tissues. A whole-body composition includes metrics of bone density for the whole body, but the scan does not replace a dedicated/focused hip and spine bone density examination for diagnosing or monitoring osteoporosis and its treatment. That would be a separate examination in addition to the full body scan.

You will lie on your back on an open scanning table while the scanner arm passes over you. Scanning usually takes about 10 minutes; a DXA-only visit is approximately 25 minutes including setup and discussion. Remain awake and still, and follow positioning instructions. Speak up if you have a problem. Wait for staff before leaving the table, then sit up and stand slowly. Movement or technical problems may require a repeat scan; staff will explain the reason before proceeding.

Risks: The scan is usually painless, but lying still or changing position may cause discomfort or dizziness. DXA uses a small amount of ionizing radiation. The dose depends on the scanner, scan mode and any repeat scans. Radiation carries a very small potential long-term cancer risk; it is not risk-free. Elective DXA body composition testing must be deferred during pregnancy or while possible pregnancy is being evaluated.

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

Resting metabolic rate testing

Resting metabolic rate (RMR) testing uses breath analysis, called indirect calorimetry, to estimate the calories your body uses at rest for functions such as breathing and circulation. You will rest in a chair and breathe room air through a disposable mouthpiece connected to the analyzer. A nose clip helps direct your breath through the mouthpiece. Measurement usually takes about 12 minutes, with additional time for rest, setup and discussion.

Keep a gentle, complete seal around the mouthpiece, breathe normally, remain awake and relaxed, and avoid talking or moving. Do not deliberately breathe faster, slower or deeper. Notify staff immediately if you feel uncomfortable.

Risks: RMR testing uses no X-rays or injections. The mouthpiece or nose clip may cause temporary discomfort, dry mouth, gagging or anxiety. Tell staff if you develop dizziness, breathing difficulty or other symptoms. The test can be stopped at any time.

2.  Preparing for your appointment

These are our clinic preparation instructions for consistent testing. If you are having both tests, follow both sets of instructions and use the longer RMR fasting period. Tell staff if you could not follow an instruction; we may need to adjust or reschedule testing.

For either test

·       Wear comfortable, loose-fitting clothing. Arrive well-rested, allow time to avoid rushing, and tell us if any preparation instruction is difficult for you to follow.

·       Plain water is allowed during fasting. Arrive normally hydrated. Do not intentionally dehydrate yourself or drink unusually large amounts of water immediately before testing.

·       Continue prescribed medicines as directed by your healthcare provider. Do not stop or change them solely for testing.

·       If you have diabetes, a history of low blood sugar, medicines that must be taken with food, or another reason fasting may be unsafe and we do not recommend it. If symptoms occur, treat them as directed by your clinician and tell our team; do not continue fasting just to complete a test.

If you are having a DXA scan

·       Food: For DXA alone, do not eat or drink anything except plain water for at least 2 hours before your appointment.

·       Calcium: Avoid calcium supplements for 24 hours before the scan, including calcium-containing multivitamins and calcium-based antacids such as TUMS. If calcium is prescribed or medically necessary, ask your clinician and our office before changing it.

·       Clothing and metal: Choose clothing with minimal or no metal, preferably loose athletic clothing. Avoid tight waistbands and restrictive garments. Remove watches, jewelry, belts, glasses, hats, removable hair accessories and shoes as instructed. Empty all pockets, including keys and coins. Small fixed buttons or zippers may be acceptable if staff confirm they will not interfere.

·       Exercise: Avoid exercise for 12 hours before the appointment, including strenuous activity earlier that day, and arrive rested.

·       Recent imaging: Contact us before the appointment (sam@dexascanboston.com) if you recently received barium, oral or intravenous contrast, a nuclear medicine tracer, or another imaging agent that may remain in the body. Provide the procedure, date and agent if known. These agents can affect the scan. Staff will determine the appropriate timing; there is no single waiting period that applies to every agent.

If you are having RMR testing

·       Caffeine: It is ideal to have a 12-hour period before your appointment with no caffeine, including caffeinated coffee, tea, energy drinks and other caffeinated products.

·       Other substances:

·       Avoid alcohol for at least 24 hours.

·       Avoid caffeine, energy drinks, pre-workout products and nonprescription stimulant supplements for at least 12 hours.

·       Avoid nicotine—including smoking, vaping and nicotine pouches—for at least 6 hours.

·       Prescribed medicines should still be taken as directed by your clinician.

·       Food and drinks: Do not eat or drink anything except plain water for at least 8 hours before RMR testing.

·       Exercise: Avoid strenuous exercise for at least 12 hours before testing. Avoid significant activity immediately beforehand and do not exercise on your way to the appointment. For a combined appointment, also follow the DXA exercise instructions above.

·       Rest: Arrive relaxed and allow time to sit quietly before measurement. Follow the technician's instructions about resting, positioning and breathing.

3  Information to tell our team before testing

-Whether you are pregnant or possibly pregnant. Possible pregnancy requires review before DXA; staff may recommend a pregnancy test or postponement.

-Recent contrast, barium or nuclear imaging

-Any implants, attached devices, difficulty lying flat or moving, or concerns about fitting safely on the scan table. Do not remove an essential medical device on your own.

-Any current illness, breathing or fasting concerns, or preparation steps you could not follow

4  Understanding results and alternatives

Results reflect the testing conditions. Food, hydration, exercise, medicines, illness, positioning, movement and equipment differences can affect measurements. Small changes between visits may reflect measurement variation. Similar preparation and, when possible, the same equipment help comparisons over time.

RMR is only part of daily calorie needs; activity and food processing also use energy. It helps a clinician or dietitian estimate intake, but does not provide an exact calorie target, diagnose a hormonal disorder or guarantee weight loss. Neither test replaces a medical evaluation or guarantees disease prevention. Discuss concerning results with your treating clinician.

You may decline testing. Alternatives include weight and waist tracking, other body composition methods, and calorie estimates from predictive equations. These offer different information and have limitations. Discuss a dedicated bone density examination with your clinician if osteoporosis assessment is needed.

5  Payment and follow up

These elective/concierge services are self-pay. DEXA Scan Boston is not credentialed for any insurances for these services, and does not submit insurance claims for these appointments, and no out-of-network insurance reimbursement is possible. I agree to the fee disclosed before testing.

There are usually no activity or driving restrictions afterward. Resume eating and usual activities when you feel well, following individual instructions. Before leaving, report symptoms and ask about results and any needed follow-up.

6  My consent

I have read this form. I understand the selected tests, preparation, possible benefits, risks, limitations and alternatives. My information provided and that I will provide is accurate to the best of my knowledge, and I will report changes before testing.

I voluntarily consent to the test or tests I have signed up for. I may decline either test or ask to stop at any time. If signing electronically, I intend my electronic signature to indicate consent.