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Listed below are some statements that people may make about themselves. Please read the statements carefully and put a check in the box marked YES if the statement applies to you. Check the box marked NO if the statement does not apply to you.

Please answer every item. If you are not sure whether to answer YES or NO, check whichever answer you think is most true.

Acromegaly Survey

Directions for completing questionnaire:
  • Demographics:
  • General: Please give all numerical information rounded to nearest whole number.
  • Examples: 1 year 6 months = 2 yrs.
Gender:
Level of Education:
Income Level:
Marital Status:
Present Age:
Country You Live In:
State/Province you live in:
Do you have a family history of acromegaly:
→ If yes, what relationship:
Have you had a pituitary tumor removed:
Are you on medication for your acromegaly:
→ If yes, what medication:
Who first diagnosed your acromegaly:
→ If other, who:
At what age were you diagnosed with acromegaly:
Estimate how many years from start of your first sign or symptom of acromegaly to time of being diagnosed with acromegaly:

Listed below are signs and symptoms of acromegaly. Review those signs or symptoms that you had. In the Occurance column, number the symptoms you had in order that they occurred, 1 being the first sign or symptom and going up numerically. In the Years Had column, estimate how many years the sign or symptom occurred before being diagnosed with acromegaly. If you did not have a particular sign or symptom leave the number at 0 for that symptom.

Sign or Symptom Before Diagnosed Occurance Years Had
Acral Enlargement (did not have = 0) (did not have = 0)
Soft tissue growth
Enlargement of hands
Enlarged shoe size
Change in ring size
Increased Perspiration (did not have = 0) (did not have = 0)
Sweating
Headaches (did not have = 0) (did not have = 0)
Migraines
Tension
Cluster
Paresthesias (did not have = 0) (did not have = 0)
Numbness or burning of hands or feet
Carpal tunnel syndrome
Glucose Intolerance (did not have = 0) (did not have = 0)
Diabetes
Elevated blood sugar
Cardiovascular (did not have = 0) (did not have = 0)
Heart failure
Heart attack
Enlarged heart
Hypertension (did not have = 0) (did not have = 0)
High blood pressure
Goiter (did not have = 0) (did not have = 0)
Enlarged thyroid
Thyroid nodule
Menstrual Disorders (did not have = 0) (did not have = 0)
Irregular bleeding
Absence of periods
Decreased Libido (did not have = 0) (did not have = 0)
Impotence
Visual Disturbances (did not have = 0) (did not have = 0)
Tunnel vision
Loss of vision
Psychological (did not have = 0) (did not have = 0)
Depression
Anxiety



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One in Five Develop or Harbor Pituitary Tumors Trusted Content Provider The only disability in life is a bad attitude ~ Scott Hamilton
Disclaimer: PNA does not engage in the practice of medicine. It is not a medical authority, nor does it claim to have medical expertise. In all cases, PNA recommends that you consult your own physician regarding any course of treatment or medication. Contact Us