Pituitary Network Association - Patient Self Assessment Form

Patient Self Assessment Form

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.

Rate each of the following symptoms using the scale below:

0 - None
1 - Mild
2 - Moderate
3 - Severe

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

Constitutional		Eyes
Weight Gain (how many pounds?)		Loss Of Peripheral Vision
Weight Loss (how many pounds?)		Blurred Vision
Height Loss (how many inches?)		Double Vision
Fevers		Neck
Chills		Difficulty Swallowing
Sweating		Voice Hoarseness
Hot Flashes		Respiratory
Cold Intolerance		Cough
Heat Intolerance		Shortness Of Breath
Fatigue		Breasts
Decreased Endurance		Enlargement/Fullness
Snoring		Pain
Difficulty Falling Asleep At Night		Discharge If so, what color
Sleepy During The Day		Heart
Muscle-skeletal		Palpitations
Joint Aches/Pain		Chest Pain Or Pressure
Joint Swelling		Skin
Muscle Weakness		Oily Skin
Gastrointestinal		Dry Skin
Diarrhea		Skin Tags
Constipation		Acne
Nausea		Easy Bruising
Abdominal Pain		Purple Stretch Marks
Bloody Stool		Urinary
Neurological		Excessive Thirst
Headaches		Excessive Urination
Seizures		Number Of Times You Awaken At Night To Urinate
Mood/Thinking		Habits
Angry		Alcohol Use
Depressed		Tobacco Use
Crying		Recreational Drug Use
Irritability
Mood Swings
Anxious
Nervous
Feel Violent		`
Low Self-esteem
Decreased Enjoyment Of Life
Wish To Be Alone
Forgetful
Difficulty Concentrating
For Women Only		For Men Only
Age At Onset Of Menses		Problems With Sex Drive
Date Of Last Menstrual Period		Problems With Erection
Cycle Duration		Ejaculation Problem
Amount Of Menstrual Flow		Testicles Shrinking
Vaginal Dryness		Infertility
Problems With Sex Drive (libido)		Hair Loss
Pain During Sex
Infertility
Excessive Facial Hair
Hair Loss

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The Pituitary Patient Resource Guide is the ONLY publication of its kind available to patients, their families, primary care physicians, insurance companies, and employers.

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Last Revised : January 2006