We are creating a Cushing’s Syndrome Register. Currently there is none available in the United States. If you’ve been diagnosed with Cushing’s Syndrome, keeping in mind that Cushing’s Disease is also Cushing’s Syndrome, would you please take a few moments and fill out this questionnaire.

The information you provide will be used to create a register and will be shared with the medical world. No names or identifying information will be used. It would not be used for other purposes without your expressed permission. This information will not be sold or shared with other companies.

Lynne Clemens, Secretary of CUSH Org. will be the person responsible for the creation of this register. If you have any questions you may contact her at lynnecush@comcast.net. You do not have to be a member of CUSH to fill out this questionnaire, only a Cushing’s patient. We do not believe that the world has an accurate accounting of Cushing’s patients. The only way to authenticate accuracy is with actual numbers. Your help will be appreciated. Thank you.

If you fill out this questionnaire and have not had surgery or if you have any changes in your health as a result of Cushing’s we would ask that you update your information.

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Your name:

Name
Date of Birth
Sex	Male Female

Address:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
E-mail

Approximate age at onset:

Under 10	21 - 30	41 - 50
11 - 20	31 - 40	Over 51

Age at diagnosis

Age

Cortisol reading at diagnosis, if known?

Diagnosis besides Cushing's, Please check all that apply:

Addison's	Carney Complex	Nelson's
Cancer	Conn's	Recurrent Cushing's

Type of Cushing's, Please check all that apply:

Adrenal	Cyclical	Gestational
Chemotherapy	Ectopic	Pituitary
Steroid Use

Pituitary Surgery:

First Pituitary Surgery? mm/dd/yy

Second Surgery? mm/dd/yy

Third Pituitary Surgery? mm/dd/yy

Adrenal Surgery?

First Adrenal Surgery? mm/dd/yy

Second Adrenal Surgery? mm/dd/yy

Etopic Surgery?

Ectopic Surgery mm/dd/yy

Second Etopic Surgery? mm/dd/yy

Radiation?

First Radiation mm/dd/yy

Second Radiation? mm/dd/yy

Gamma Knife?

First Gamma Knife? mm/dd/yy

Second Gamma Knife? mm/dd/yy

Are you on Growth Hormone?

yes no

Other drugs related to your Cushing's?
Please list the name and what it is used for

Do you now have any other illness/disease as a result of having had Cushing's?

Did you have any other surgeries as a result of having had Cushing's?

Other information you might consider important.

                

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Thanks for Participating!

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