Patient Questionaire

Patient Questionaire

We request your cooperation in completing the following survey questions. The answers will help us to develop a model that will assist both past and future pituitary patients; influencing legislation, the medical community, research projects and patient care.

Patient Information

Name
Address
Sex

Diagnosis Physician

Name
Address

Diagnosis

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

Treatment

Have you had radiation treatment? (check all that apply)
Was it the first time you ever presented your symptoms to this person?
Were you ever misdiagnosed?
Have you ever had the following? (Check all that apply)

Reproductive System: Women

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

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?
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 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 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 mental confusion?
Have you kept your condition from your family?

Medications

Have you or are you taking any of the following drugs or medications:
Do you have side effects?
Do you find your skin is easily infected?
Do you suffer from strange rashes?
If so, are they purple?
Do you bruise easily?
o you have trouble regulating your body temperature?

Visual

Have you had a vision change?

Respiratory System

Do you suffer from sleep apnea?
Do you have insomnia or trouble falling asleep?

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.

Name
Address

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

Name
Address
Seventh Edition - Coming Soon!

The Pituitary Patient Resource Guide Sixth Edition is now available! Be one of the first to have the most up-to-date information.

The Pituitary Patient Resource Guide a one of a kind publication intended as an invaluable source of information not only for patients but also their families, physicians, and all health care providers.

It contains information on symptoms, proper testing, how to get a diagnosis, and the treatment options that are available. It also includes Pituitary Network Association’s patient resource listings for expert medical care.

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