Research - Patient Questionnaire | Pituitary Network Association

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Patient Questionnaire

General Information

First Name:

Last Name:

Address:

Apartment:

City:

State/Province:

Zip/Post Code:

Country:

E-mail:

Sex:

Age:

Please give us some information about your diagnosing physician/health care provider.

First Name:

Last Name:

Address:

Suite:

City:

State/Province:

Zip/Post Code:

Country:

Diagnosis

Have you been diagnosed with one or more of the following: (check all that apply)

AcromegalyGrowth Hormone DeficiencyMEN 1
Adrenal TumorsHypopituitarismNon Functioning
CraniopharyngiomaHyperthyroidismProlactinoma
Cushing'sHypothyroidismRathke's Cleft Cyst
Ectopic ACTH SyndromeLH/FSH SecretingTSH Secreting
Empty Sella Syndrome

Have you had radiation treatment? (check all that apply)

Gamma KnifePeacock systemConventional radiation
LinAcCyber KnifeOther
Proton beamRadioactive seed implantation

What was your age at diagnosis?

What was the specialty of your diagnosing physician?

Was it the first time you ever presented your symptoms to this person?

Were you ever misdiagnosed?
(e.g. Continually complained of the same symptoms but couldn't receive a proper diagnosis)

Have you ever had the following: (check all that apply)

Transsphenoidal - Under lipPetrosal sinus sampling
Transsphenoidal - Through noseDexamethasone CRH test
CraniotomyOctreoscan
MRT assisted surgeryAngiogram
Stealth procedureA new technique
Endoscopic procedure

How many courses of treatment did you receive?
(Radiation or other treatment/procedure)

Reproductive System: Women

What age did your menstrual cycle begin?

Did you have a sudden change in your cycle prior to diagnosis?

Are you currently taking medication to regulate your cycle?

Are you currently trying to get pregnant?

Do you or have you suffered from loss of libido?

Has intercourse now or in the past become painful?

Do you or have you suffered from vaginal dryness?

Have you ever had a milky breast discharge?

Do you now or have you had breast cyst(s)?

Do you have or have you had breast cancer?

Do you or have you had ovarian or uterine cysts?

Reproductive System: Men

Approximate age when you went through puberty?

Do you or have you suffered from loss of libido?

Do you or have you suffered from impotence?

Do you have hypogonadism (small testes)?

Have you ever had a milky discharge from either or both breasts?

Endocrine System

Are you currently under the care of a pituitary endocrinologist?

Do you have diabetes?

Are your hormone levels currently in the normal range?

Are you taking hormone replacement medication?

Do you have thyroid disease?

Do you have allergies?

Have you had rapid weight gain or loss?

Do you have regularly scheduled MRI's?

Urinary System

Have you suffered from diabetes insipidus (DI)?

Have you ever had kidney stones?

Have you experienced kidney infections?

If male, have you had prostate problems?

Muscular-Skeletal Neurological Systems

Do you have or have you had muscle pains?

Do you have arthritis?

Have you experienced pain in your joints?

Have you ever had any joints surgically replaced?

Have you ever had bone spurs?

Have you been diagnosed with fibromyalgia?

Have you had an increase in height?

Have you ever had a bone density test?

Do you suffer from bone loss or osteoporosis?

Have you had trouble supporting your weight?

Have you had difficulty performing daily activities?

Cardiovascular System

Have you suffered from irregular heartbeat?

Have you had hypertension (high blood pressure)?

Is your heart enlarged; cardiomegaly?

Are you partially or totally blind?

Psychological

Have you experienced increased anger and/or fits of rage?

Have you experienced lack of enthusiasm or desire?

Have you ever been anxious or had unusual fears?

Are you depressed?

Do you suffer from clinical depression?

Are you taking medication for your depression?

Do you have memory loss?

Do you have mental confusion?

Overall how has your family dealt with your condition?

Have you kept your condition from your family?

Medications

Have you or are you taking any of the following drugs or medications:

Anti DepressantsLevathyroxine
Bromocriptine (Parlodel)Levothroid
Cabergoline (Dostinex)Levoxyl
CortefNorprolac
CortisolOctreotide Acetate (Sandostatin)
DilantinPermax
DDAVPPrednisone
EstrogenRitalin
GenotropinSynthroid
Growth HormoneTestosterone
HumatropeVasopressin
LanreotideOther Medication

Do you have side effects?

Do you find your skin is easily infected?

Do you suffer from strange rashes?

Do you have striae (stretch marks)?

If so, are they purple?

Do you bruise easily?

Do you have trouble regulating your body temperature?

Visual

Have you had a vision change?

Has surgery changed your vision?

Respiratory System

Do you suffer from sleep apnea?

Do you have insomnia or trouble falling asleep?

Are you short of breath?

Soft Tissue and Skin

Have you had sudden hair loss?

In general would you consider your skin thick or thin?

Do you have unusual fat deposits in your neck?

Do you have a moon or round face?

Do you have skin tags (small flesh colored moles)?

Please give us some information about the physician that treated you during your illness.

First Name:

Last Name:

Address:

Suite:

City:

State/Province:

Zip/Post Code:

Country:

Please give us some information about the physician that is currently treating you.

First Name:

Last Name:

Address:

Suite:

City:

State/Province:

Zip/Post Code:

Country:

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