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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 VisionNone Mild Moderate Severe
Blurred VisionNone Mild Moderate Severe
Double VisionNone Mild Moderate Severe
CONSTITUTIONAL
Weight Gain (how many pounds?)__________
Weight Loss (how many pounds?)__________
Height Loss (how many inches?)__________
FeversNone Mild Moderate Severe
ChillsNone Mild Moderate Severe
SweatingNone Mild Moderate Severe
Hot FlashesNone Mild Moderate Severe
Cold IntoleranceNone Mild Moderate Severe
Heat IntoleranceNone Mild Moderate Severe
FatigueNone Mild Moderate Severe
Decreased EnduranceNone Mild Moderate Severe
SnoringNone Mild Moderate Severe
Difficulty Falling Asleep At NightNone Mild Moderate Severe
Sleepy During The DayNone Mild Moderate Severe
NECK
Difficulty SwallowingNone Mild Moderate Severe
Voice HoarsenessNone Mild Moderate Severe
RESPIRATORY
CoughNone Mild Moderate Severe
Shortness Of Breath None Mild Moderate Severe
BREAST CHANGES
Enlargement/FullnessNone Mild Moderate Severe
PainNone Mild Moderate Severe
DischargeNone Mild Moderate Severe
If so, what color__________
HEART
PalpitationsNone Mild Moderate Severe
Chest Pain Or PressureNone Mild Moderate Severe
MUSCLES AND BONES
Joint Aches/PainNone Mild Moderate Severe
Joint SwellingNone Mild Moderate Severe
Muscle WeaknessNone Mild Moderate Severe
SKIN
Oily SkinNone Mild Moderate Severe
Dry SkinNone Mild Moderate Severe
Skin TagsNone Mild Moderate Severe
AcneNone Mild Moderate Severe
BruisingNone Mild Moderate Severe
Purple Stretch MarksNone Mild Moderate Severe
GASTROINTESTINAL
DiarrheaNone Mild Moderate Severe
Constipation None Mild Moderate Severe
NauseaNone Mild Moderate Severe
Abdominal PainNone Mild Moderate Severe
Bloody StoolNone Mild Moderate Severe
URINARY PROBLEMS
Excessive ThirstNone Mild Moderate Severe
Excessive UrinationNone Mild Moderate Severe
Number Of Times You Awaken At Night To Urinate__________
NEUROLOGICAL
HeadachesNone Mild Moderate Severe
SeizuresNone Mild Moderate Severe
MOOD/THINKING
AngryNone Mild Moderate Severe
DepressedNone Mild Moderate Severe
CryingNone Mild Moderate Severe
IrritabilityNone Mild Moderate Severe
Mood SwingsNone Mild Moderate Severe
AnxiousNone Mild Moderate Severe
NervousNone Mild Moderate Severe
Feel ViolentNone Mild Moderate Severe
Low Self-esteemNone Mild Moderate Severe
Decreased Enjoyment Of LifeNone Mild Moderate Severe
Wish To Be AloneNone Mild Moderate Severe
ForgetfulNone Mild Moderate Severe
Difficulty ConcentratingNone Mild Moderate Severe
HABITS
Alcohol UseNone Mild Moderate Severe
Tobacco UseNone Mild Moderate Severe
Recreational Drug UseNone Mild Moderate Severe
FOR WOMEN ONLY
Age At Onset Of Menses__________
Problems With Sex DriveNone 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 SexNone 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 ErectionNone 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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