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

First Last

Address

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

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)

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

Were you ever misdiagnosed?

Yes

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

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

Are you currently trying to get pregnant?

Yes

Do you or have you suffered from loss of libido?

Moderate

Severe

Has intercourse now or in the past become painful

Yes

Do you or have you suffered from vaginal dryness?

Yes

Have you ever had a milky breast discharge?

Yes

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

Yes

Do you have or have you had breast cancer?

Yes

Do you or have you had ovarian or uterine cysts?

Yes

Reproductive System: Men

What age did your menstrual cycle begin?

Do you or have you suffered from loss of libido?

Moderate

Severe

Do you or have you suffered from impotence?

Yes

Do you have hypogonadism (small testes)?

Yes

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

Yes

Endocrine System

Are you currently under the care of a pituitary endocrinologist?

Yes

Do you have diabetes?

Yes

Are your hormone levels currently in the normal range?

Yes

Are you taking hormone replacement medication?

Yes

Do you have thyroid disease?

Yes

Do you have allergies?

Yes

Have you had rapid weight gain or loss?

Yes

Do you have regularly scheduled MRI's?

Yes

Urinary System

Have you suffered from diabetes insipidus (DI)?

Yes

Have you ever had kidney stones?

Yes

Have you experienced kidney infections?

Yes

Have you experienced kidney infections?

Yes

If male, have you had prostate problems?

Yes

Muscular-Skeletal Neurological Systems

Do you have or have you had muscle pains?

Yes

Do you have arthritis?

Yes

Have you experienced pain in your joints?

Yes

Have you ever had any joints surgically replaced?

Yes

Have you ever had bone spurs?

Other(Required)

Have you been diagnosed with fibromyalgia?

Yes

Have you had an increase in height?

Yes

Have you ever had a bone density test?

Yes

Do you suffer from bone loss or osteoporosis?

Yes

Have you had trouble supporting your weight?

Yes

Have you had difficulty performing daily activities?

Yes

Cardiovascular System

Have you suffered from irregular heartbeat?

Have you had hypertension (high blood pressure)?

Yes

Is your heart enlarged; cardiomegaly?

Yes

Are you partially or totally blind?

Yes

Psychological

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

Yes

Have you experienced lack of enthusiasm or desire?

Yes

Have you ever been anxious or had unusual fears?

Yes

Are you depressed?

Yes

Do you suffer from clinical depression?

Yes

Are you taking medication for your depression?

Yes

Do you have memory loss?

Do you have mental confusion?

Yes

Overall how has your family dealt with your condition?

Have you kept your condition from your family?

Yes

Medications

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

Do you have side effects?

Yes

Do you find your skin is easily infected?

Yes

Do you suffer from strange rashes?

Yes

Do you have striae (stretch marks)?

Other(Required)

If so, are they purple?

Yes

Do you bruise easily?

Yes

o you have trouble regulating your body temperature?

Yes

Visual

Have you had a vision change?

Yes

Has surgery changed your vision?

Respiratory System

Do you suffer from sleep apnea?

Yes

Do you have insomnia or trouble falling asleep?

Yes

Are you short of breath?

Soft Tissue and Skin

Have you had sudden hair loss?

Yes

In general would you consider your skin thick or thin?

Thick

Thin

Do you have unusual fat deposits in your neck?

Yes

Do you have a moon or round face?

Yes

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

Yes

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

51328

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Available Now!

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