From Mary Shomon Your Thyroid Guide
Do You Have a Pituitary Problem? Self-Assessment Questionnaire
May 2001
Fill out this self-assessment form and take it to your doctor for discussion and further evaluation. When finished, print the form and take with you to your physician.
EYES Loss of Peripheral Vision None Mild Moderate Severe Blurred Vision None Mild Moderate Severe Double Vision None Mild Moderate Severe CONSTITUTIONAL Weight Gain (how many pounds?) __________ Weight Loss (how many pounds?) __________ Height Loss (how many inches?) __________ Fevers None Mild Moderate Severe Chills None Mild Moderate Severe Sweating None Mild Moderate Severe Hot Flashes None Mild Moderate Severe Cold Intolerance None Mild Moderate Severe Heat Intolerance None Mild Moderate Severe Fatigue None Mild Moderate Severe Decreased Endurance None Mild Moderate Severe Snoring None Mild Moderate Severe Difficulty Falling Asleep At Night None Mild Moderate Severe Sleepy During The Day None Mild Moderate Severe NECK Difficulty Swallowing None Mild Moderate Severe Voice Hoarseness None Mild Moderate Severe RESPIRATORY Cough None Mild Moderate Severe Shortness Of Breath None Mild Moderate Severe BREAST CHANGES Enlargement/Fullness None Mild Moderate Severe Pain None Mild Moderate Severe Discharge None Mild Moderate Severe If so, what color __________ HEART Palpitations None Mild Moderate Severe Chest Pain Or Pressure None Mild Moderate Severe MUSCLES AND BONES Joint Aches/Pain None Mild Moderate Severe Joint Swelling None Mild Moderate Severe Muscle Weakness None Mild Moderate Severe SKIN Oily Skin None Mild Moderate Severe Dry Skin None Mild Moderate Severe Skin Tags None Mild Moderate Severe Acne None Mild Moderate Severe Bruising None Mild Moderate Severe Purple Stretch Marks None Mild Moderate Severe GASTROINTESTINAL Diarrhea None Mild Moderate Severe Constipation None Mild Moderate Severe Nausea None Mild Moderate Severe Abdominal Pain None Mild Moderate Severe Bloody Stool None Mild Moderate Severe URINARY PROBLEMS Excessive Thirst None Mild Moderate Severe Excessive Urination None Mild Moderate Severe Number Of Times You Awaken At Night To Urinate __________ NEUROLOGICAL Headaches None Mild Moderate Severe Seizures None Mild Moderate Severe MOOD/THINKING Angry None Mild Moderate Severe Depressed None Mild Moderate Severe Crying None Mild Moderate Severe Irritability None Mild Moderate Severe Mood Swings None Mild Moderate Severe Anxious None Mild Moderate Severe Nervous None Mild Moderate Severe Feel Violent None Mild Moderate Severe Low Self-esteem None Mild Moderate Severe Decreased Enjoyment Of Life None Mild Moderate Severe Wish To Be Alone None Mild Moderate Severe Forgetful None Mild Moderate Severe Difficulty Concentrating None Mild Moderate Severe HABITS Alcohol Use None Mild Moderate Severe Tobacco Use None Mild Moderate Severe Recreational Drug Use None Mild Moderate Severe FOR WOMEN ONLY Age At Onset Of Menses __________ Problems With Sex Drive None Mild Moderate Severe
Date Of Last Menstrual Period __________ Cycle Duration __________ Amount Of Menstrual Flow __________ Vaginal Dryness? None Mild Moderate Severe Problems With Sex Drive (libido) None Mild Moderate Severe Pain During Sex None Mild Moderate Severe Infertility? None Mild Moderate Severe Excessive Facial Hair? None Mild Moderate Severe Hair Loss? None Mild Moderate Severe FOR MEN ONLY Problems With Erection None Mild Moderate Severe Premature Ejaculation Problem None Mild Moderate Severe Testicles Shrinking? None Mild Moderate Severe Infertility? None Mild Moderate Severe Hair Loss None Mild Moderate Severe
For more information, see: One Out of Five Adults Worldwide May Have a Pituitary Tumor
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