Patient Self Assessment

The Importance of Research

This form is for you to fill out and take to your physician. This self-assessment is not to be used for diagnosing any tumor or disorder. Only your physician can do that. But by rating each symptom/condition on this form using a simple 4 point scale, you can help your physician to best understand exactly what you are feeling.

* When finished, this form with your answeres will be emailed to you.

Constitutional

Fevers
Chills
Sweating
Hot Flashes
Cold Intolerance
Heat Intollerance
Fatigue
Decreased Endurance
Snoring
Difficulty Falling Asleep At Night
Sleepy During The Day

Eyes

Loss Of Peripheral Vision
Blurred Vision
Double Vision

Double Vision

Difficulty Swallowing
Voice Hoarseness

Respiratory

Cough
Shortness Of Breath

Shortness Of Breath

Enlargement/Fullness
Pain

Heart

Palpitations
Chest Pain Or Pressure

Muscle-Skeletal

Joint Aches/Pain
Joint Swelling
Muscle Weakness

Skin

Oily Skin
Dry Skin
Sking Tags
Latom
Acne
Easy Bruising
Purple Stretch Marks

Gastrointestinal

Diarrhea
Constipation
Nausea
Abdominal Pain
Bloody Stool

Urinary

Excessive Thirst
Excessive Urination

Neurological

Headaches
Seizures

Mood/Thinking

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

Angry
Depressed
Crying
Irritability
Mood Swings
Anxious
Nervous
Feel Violent
Low Self-esteem
Decreased Enjoyment Of Life
Wish To Be Alone
Forgetful
Difficulty Concentrating

Habits

Alcohold Use
Tobacco Use
Recreational Drug Use

For Men Only

Problems With Sex Drive
Problems With Erection
Ejaculation Problem
Infertility
Hair Loss

For Women Only

Amount Of Menstrual Flow
Vaginal Dryness
Problems With Sex Drive (libido)
Pain During Sex
Infertility
Excessive Facial Hair
Hair Loss

Available Now!

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.

Buy Now

PNA Gratefully Acknowledges our Supporters

Continuing Education Program

If you are a nurse or medical professional, register for PNA CEU Membership and  earn CEU credits to learn about the symptoms, diagnosis and treatment options for patients with pituitary disorders. Help PNA reduce the time it takes for patients to get an accurate diagnosis.

Register Now!

For more information click here!

Coming Events

Dr Garni Barkhoudarian to be awarded Gentle Giant

Helpful Resources

Pituitary Patient Tool Kit

Check out our new educational tools!

Downloadable Pituitary Brochures

Our print quality brochures are now available for download.