Pituitary Network Association - Patient Questionnaire

Patient Questionnaire

This questionnaire was compiled by: Morton A. Hirschberg, Trisha McNamara & Claire Freda

The purpose of this questionnaire is to gather data for pituitary research. Your name and all identifying information will remain totally confidential but we request your name and mailing address so that we may furnish you with new information and knowledge about your condition as it becomes available.

First Name:		Last Name:

Address:		Apartment:

City:		State/Province:

Zip/Post Code:		Country:

E-mail:

Sex:		Age:

Please give us some information about your diagnosing physician/health care provider.
First Name:	Last Name:

Address:	Suite:

City:	State/Province:

Zip/Post Code:	Country:

Have you been diagnosed with one or more of the following: (check all that apply)
	Acromegaly
	Adrenal Tumors
	Craniopharyngioma
	Cushing's
	Ectopic ACTH Syndrome
	Empty Sella Syndrome
	Growth Hormone Deficiency
	Hypopituitarism
	Hyperthyroidism
	Hypothyroidism
	LH/FSH Secreting
	MEN 1
	Non Functioning
	Prolactinoma
	Rathke's Cleft Cyst
	TSH Secreting
Have you had radiation treatment? (Check all that apply)
	Gamma Knife
	LinAc
	Proton beam
	Peacock system
	Cyber Knife
	Radioactive seed implantation
	Conventional radiation
	Other

What was your age at diagnosis?

What was the specialty of your diagnosing physician?

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

Were you ever misdiagnosed? (e.g. Continually complained of the same symptoms but couldn't receive a proper diagnosis)

Have you ever had the following: (Check all that apply)
	Transsphenoidal - Under lip
	Transsphenoidal - Through nose
	Craniotomy
	MRT assisted surgery
	Stealth procedure
	Endoscopic procedure
	Petrosal sinus sampling
	Dexamethasone CRH test
	Octreoscan
	Angiogram
	A new technique

How many courses of treatment did you receive? (Radiation or other treatment/procedure)
REPRODUCTIVE SYSTEM: WOMEN
What age did your menstrual cycle begin?
Did you have a sudden change in your cycle prior to diagnosis?
Are you currently taking medication to regulate your cycle?
Are you currently trying to get pregnant?
Do you or have you suffered from loss of libido?
Has intercourse now or in the past become painful?
Do you or have you suffered from vaginal dryness?
Have you ever had a milky breast discharge?
Do you now or have you had breast cyst(s)?
Do you have or have you had breast cancer?
Do you or have you had ovarian or uterine cysts?
REPRODUCTIVE SYSTEM MEN
Approximate age when you went through puberty?
Do you or have you suffered from loss of libido?
Do you or have you suffered from impotence?
Do you have hypogonadism (small testes)?
Have you ever had a milky discharge from either or both breasts?

ENDOCRINE SYSTEM
Are you currently under the care of a pituitary endocrinologist?
Do you have diabetes?
Are your hormone levels currently in the normal range?
Are you taking hormone replacement medication?
Do you have thyroid disease?
Do you have allergies?
Have you had rapid weight gain or loss?
Do you have regularly scheduled MRI's?

URINARY SYSTEM
Have you suffered from diabetes insipidus (DI)?
Have you ever had kidney stones?
Have you experienced kidney infections?
If male, have you had prostate problems?
MUSCULAR-SKELETAL NEUROLOGICAL SYSTEMS
Do you have or have you had muscle pains?
Do you have arthritis?
Have you experienced pain in your joints?
Have you ever had any joints surgically replaced?
Have you ever had bone spurs?
Have you been diagnosed with fibromyalgia?
Have you had an increase in height?
Have you ever had a bone density test?
Do you suffer from bone loss or osteoporosis?
Have you had trouble supporting your weight?
Have you had difficulty performing daily activities?

CARDIOVASCULAR SYSTEM

Have you suffered from irregular heartbeat?

Have you had hypertension (high blood pressure)?

Is your heart enlarged; cardiomegaly?

Are you partially or totally blind?

PSYCHOLOGICAL

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

Have you experienced lack of enthusiasm or desire?

Have you ever been anxious or had unusual fears?

Are you depressed?

Do you suffer from clinical depression?

Are you taking medication for your depression?

Do you have memory loss?

Do you have mental confusion?

Overall how has your family dealt with your condition?

Have you kept your condition from your family?

MEDICATIONS

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

	Anti Depressants		Bromocriptine (Parlodel)
	Cabergoline (Dostinex)		Cortef
	Cortisol		Dilantin
	DDAVP		Estrogen
	Genotropin		Growth Hormone
	Humatrope		Lanreotide
	Levathyroxine		Levothroid
	Levoxyl		Norprolac
	Octreotide Acetate (Sandostatin)		Permax
	Prednisone		Ritalin
	Synthroid		Testosterone
	Vasopressin		Other Medication

Do you have side effects?

Do you find your skin is easily infected?

Do you suffer from strange rashes?

Do you have striae (stretch marks)?

If so, are they purple?

Do you bruise easily?

Do you have trouble regulating your body temperature?

VISUAL

Have you had a vision change?

Has surgery changed your vision?

RESPIRATORY SYSTEM

Do you suffer from sleep apnea?

Do you have insomnia or trouble falling asleep?

Are you short of breath?

SOFT TISSUE AND SKIN

Have you had sudden hair loss?

In general would you consider your skin thick or thin?

Do you have unusual fat deposits in your neck?

Do you have a moon or round face?

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

Please give us some information about the physician that treated you during your illness.
First Name:	Last Name:

Address:	Suite:

City:	State/Province:

Zip/Post Code:	Country:

Please give us some information about the physician that is currently treating you.
First Name:	Last Name:

Address:	Suite:

City:	State/Province:

Zip/Post Code:	Country:

Sign Our Guestbook

Patient Questionnaire

Acromegaly Survey

Insurance Questionnaire

Quality of Life Survey

Patient Self-Assessment Form

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

The Pituitary Patient Resource Guide now available on CD.

Purchase:
· CD

Last Revised : January 2005