Patient Questionaire

Home
Who We Are
Resources
Research
Knowledge Base
Events
Bookstore
Login

Patient Questionaire

photo_research

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

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Sex

Male

Female

Age Range(Required)

Diagnosis Physician

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Diagnosis

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

Acromegaly

Growth Hormone Deficiency

Adrenal Tumors

Hypopituitarism

Non Functioning

Craniopharyngioma

Hyperthyroidism

Prolactinoma

Cushing's

Hypothyroidism

Rathke's Cleft Cyst

Ectopic ACTH Syndrome

LH/FSH Secreting

TSH Secreting

Empty Sella Syndrome

Other

Other(Required)

Treatment

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

Gamma Knife

LinAc

Proton beam

Peacock system

Cyber Knife

Radioactive seed implantation

Conventional radiation

Other

Other(Required)

Age Range(Required)

What was the specialty of your diagnosing physician?

Other(Required)

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

Yes

No

Were you ever misdiagnosed?

Yes

No

Have you ever had the following? (Check all that apply)

Transsphenoidal - Under lip

Petrosal sinus sampling

Transsphenoidal - Through nose

Dexamethasone CRH test

Craniotomy

Octreoscan

MRT assisted surgery

Angiogram

Stealth procedure

A new technique

Endoscopic procedure

How many courses of treatment did you receive?

Reproductive System: Women

What age did your menstrual cycle begin?

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

Other Change

Are you currently taking medication to regulate your cycle?

Yes

No

Are you currently trying to get pregnant?

Yes

No

Do you or have you suffered from loss of libido?

No

Moderate

Severe

Has intercourse now or in the past become painful

Yes

No

Do you or have you suffered from vaginal dryness?

Yes

No

Have you ever had a milky breast discharge?

Yes

No

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

Yes

No

Do you have or have you had breast cancer?

Yes

No

Do you or have you had ovarian or uterine cysts?

Yes

No

Reproductive System: Men

What age did your menstrual cycle begin?

Do you or have you suffered from loss of libido?

No

Moderate

Severe

Do you or have you suffered from impotence?

Yes

No

Do you have hypogonadism (small testes)?

Yes

No

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

Yes

No

Endocrine System

Are you currently under the care of a pituitary endocrinologist?

Yes

No

Do you have diabetes?

Yes

No

Are your hormone levels currently in the normal range?

Yes

No

Are you taking hormone replacement medication?

Yes

No

Do you have thyroid disease?

Yes

No

Do you have allergies?

Yes

No

Have you had rapid weight gain or loss?

Yes

No

Do you have regularly scheduled MRI's?

Yes

No

Urinary System

Have you suffered from diabetes insipidus (DI)?

Yes

No

Have you ever had kidney stones?

Yes

No

Have you experienced kidney infections?

Yes

No

Have you experienced kidney infections?

Yes

No

If male, have you had prostate problems?

Yes

No

Muscular-Skeletal Neurological Systems

Do you have or have you had muscle pains?

Yes

No

Do you have arthritis?

Yes

No

Have you experienced pain in your joints?

Yes

No

Have you ever had any joints surgically replaced?

Yes

No

Have you ever had bone spurs?

Other(Required)

Have you been diagnosed with fibromyalgia?

Yes

No

Have you had an increase in height?

Yes

No

Have you ever had a bone density test?

Yes

No

Do you suffer from bone loss or osteoporosis?

Yes

No

Have you had trouble supporting your weight?

Yes

No

Have you had difficulty performing daily activities?

Yes

No

Cardiovascular System

Have you suffered from irregular heartbeat?

Have you had hypertension (high blood pressure)?

Yes

No

Is your heart enlarged; cardiomegaly?

Yes

No

Are you partially or totally blind?

Yes

No

Psychological

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

Yes

No

Have you experienced lack of enthusiasm or desire?

Yes

No

Have you ever been anxious or had unusual fears?

Yes

No

Are you depressed?

Yes

No

Do you suffer from clinical depression?

Yes

No

Are you taking medication for your depression?

Yes

No

Do you have memory loss?

Do you have mental confusion?

Yes

No

Overall how has your family dealt with your condition?

Have you kept your condition from your family?

Yes

No

Medications

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

Anti Depressants

Cabergoline (Dostinex)

Cortef

Cortisol

Dilantin

DDAVP

Estrogen

Genotropin

Growth Hormone

Humatrope

Lanreotide

Levothroid

Levoxyl

Norprolac

Octreotide Acetate (Sandostatin)

Permax

Prednisone

Ritalin

Synthroid

Testosterone

Vasopressin

Do you have side effects?

Yes

No

Do you find your skin is easily infected?

Yes

No

Do you suffer from strange rashes?

Yes

No

Do you have striae (stretch marks)?

Other(Required)

If so, are they purple?

Yes

No

Do you bruise easily?

Yes

No

o you have trouble regulating your body temperature?

Yes

No

Visual

Have you had a vision change?

Yes

No

Has surgery changed your vision?

Respiratory System

Do you suffer from sleep apnea?

Yes

No

Do you have insomnia or trouble falling asleep?

Yes

No

Are you short of breath?

Soft Tissue and Skin

Have you had sudden hair loss?

Yes

No

In general would you consider your skin thick or thin?

Thick

Thin

Do you have unusual fat deposits in your neck?

Yes

No

Do you have a moon or round face?

Yes

No

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

Yes

No

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

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

77418

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.

PNA Gratefully Acknowleges Our Supporters

Pituitary Network Association

The PNA is an international non-profit organization for patients with pituitary tumors and disorders, their families, loved ones, and the physicians and health care providers who treat them.

The PNA was founded in 1992 by a group of acromegalic patients in order to communicate and share their experiences and concerns. The PNA has rapidly grown to become the world’s largest and fastest growing patient advocacy organization devoted to the treatment and cure of pituitary disorders.

Trust-content-provider

NORD_MembershipLogo_Platinum_2021

Who We Are

Scientific Advisory Panel
Board of Directors
Gentle Giant Award
Contact Us
Get Involved
Pituitary Network
Association Donations
Join The PNA

Resources

Physicians
Integrative Medicine Providers
Pituitary Family Resource Center
Support Groups
Hospitals
Pituitary Centers with Multi-Disciplinary Teams
Pharmaceutical/Corporate Supporters
Integrative Medicine – Mind Body Spirit

Ayurveda
Bowenwork
CRM Comprehensive Resource Model
Naturopathic
Physical Therapy
Pilates
Our Contributors
Patient’s Bill of Rights

Knowledge Base

About Pituitary
Disorders
FAQ
Glossary
Members Library
Webinar Library
Related Links
Awareness

Login

Username

Password

Forgot your password?

Privacy Policy | Copyright © 2024 Pituitary Network Association All Rights Reserved.

Cleantalk Pixel