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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, print the form and take with you to your physician.

Patient Self Assessment Form

Rate each of the following symptoms using the scale below:
0 - None;   1 - Mild;   2 - Moderate;   3 - Severe
Constitutional
Weight Gain, how many pounds?
Weight Loss, how many pounds?
Height Loss, how many inches?
Fevers
Chills
Sweating
Hot Flashes
Cold Intolerance
Heat Intolerance
Fatigue
Decreased Endurance
Snoring
Difficulty Falling Asleep At Night
Sleepy During The Day
Eyes
Loss Of Peripheral Vision
Blurred Vision
Double Vision
Neck
Difficulty Swallowing
Voice Hoarseness
Respiratory
Cough
Shortness Of Breath
Breasts
Enlargement/Fullness
Pain
Discharge? If so, what color
Heart
Palpitations
Chest Pain Or Pressure
Muscle-skeletal
Joint Aches/Pain
Joint Swelling
Muscle Weakness
Skin
Oily Skin
Dry Skin
Skin Tags
Acne
Easy Bruising
Purple Stretch Marks
Gastrointestinal
Diarrhea
Constipation
Nausea
Abdominal Pain
Bloody Stool
Urinary
Excessive Thirst
Excessive Urination
Number Of Times You Awaken At Night To Urinate
Neurological
Headaches
Seizures
Mood/Thinking
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
Alcohol Use
Tobacco Use
Recreational Drug Use
For Men Only
Problems With Sex Drive
Problems With Erection
Ejaculation Problem
Testicles Shrinking
Infertility
Hair Loss
For Women Only
Age At Onset Of Menses
Date Of Last Menstrual Period
Cycle Duration
Amount Of Menstrual Flow
Vaginal Dryness
Problems With Sex Drive (libido)
Pain During Sex
Infertility
Excessive Facial Hair
Hair Loss



Latest R&D News

The appearance of the adrenal glands on CT in multiple endocrine neoplasia type 1
 12.13.2008   Read More

Effect of treatment with depot somatostatin analogue octreotide on (PHP) in (MEN1) patients
12.13.2008   Read More

Pituitary insufficiency after traumatic brain injury - Clinical Study
02.10.2009   Read More

Lipid lowering in diabetes mellitus
 12.07.2008   Read More

Vitamin K supplementation in postmenopausal women with osteopenia (ECKO trial): A randomized controlled trial
12.13.2008   Read More


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One in Five Develop or Harbor Pituitary Tumors Trusted Content Provider The only disability in life is a bad attitude ~ Scott Hamilton
Disclaimer: PNA does not engage in the practice of medicine. It is not a medical authority, nor does it claim to have medical expertise. In all cases, PNA recommends that you consult your own physician regarding any course of treatment or medication. Contact Us