Membership Type*
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| APPLICANTS FULL NAME |
Title*
| First Name*
| Last Name*
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| PATIENTS FULL NAME |
Title*
| First Name*
| Last Name*
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| APPLICANT’S RELATIONSHIP TO PATIENT (eg. Same person, Mother, Brother, Friend, Guardian, etc) : |
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| Or are you a Health Professional ? (eg. Doctor, Endocrine Nurse, etc.Please specify): |
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Date of birth of patient *
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Gender of Patient
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Postal Address*
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Postcode*
| State*
| Country
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Home Phone
| Work Phone
| Mobile Phone
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Preferred Email Address
| Confirm Preferred Email Address
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Alternate Email Address
| Confirm Alternate Email Address
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PITUITARY CONDITION(S) OF THE PATIENT
What pituitary condition were you ORIGINALLY diagnosed with
(please select only one)
What condition(s) do you have NOW (since treatment)?
(you may select more than one)
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| Acromegaly (tumour on the pituitary gland causing excess growth hormone) |
| Adult Growth Hormone Deficiency (severely decreased / absent growth hormone after puberty) |
| Childhood Growth Hormone Deficiency (severely decreased / absent growth hormone before puberty) |
| Craniopharyngioma (a form of cyst on the pituitary gland) |
| Cushing’s Disease (tumour on the pituitary gland causing excess ACTH and cortisol hormones) |
| Diabetes Insipidus (pituitary disorder/damage causing a lack of antidiuretic hormone (ADH /vasopressin) |
| MEN Type1 (Multiple Endocrine Neoplasia Type One) (tumours in several endocrine glands including the pituitary) |
| Hypopituitarism / Pituitary Insufficiency (lack of some, but not all pituitary hormones, in any combination) |
| Non-functioning / Non-secreting Tumour (pituitary tumour that doesn’t secrete excess hormones) |
| Panhypopituitarism (complete lack of all pituitary hormones. May be due to removal / apoplexy / infarct / haemorrhage / total damage of the pituitary gland, or a severed pituitary stalk) |
| Prolactinoma (tumour on the pituitary gland causing excess prolactin hormone) |
| Sheehan’s Syndrome / Postpartum Pituitary Necrosis (haemorrhage / infarction of pituitary during or after childbirth) |
| Other Condition (specify below) |
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General Questions
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Are you in remission?
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Growth hormone Questionnaire:
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Comments
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Treatment(s) for the Pituitary Condition(s);
Please give types/dates/hospital/number of times/trials if you wish |
Surgery
| Radiotherapy
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Medication
| Pituitary Med Names
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Other Med Names
| Medication Comments
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| I would like to receive the APF newsletter and mail-outs by either ; (Please assist the APF in reducing mailing costs by choosing Email only, if possible ) |
Mail-out plan: Please tick preference
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I heard about the APF from
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I am interested in assisting the APF in the following way:
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Donation
If you wish, you make make an additional donation with your membership payment. All donations of $2.00 or more are tax deductible. | Donation Amount
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PHONE & EMAIL PATIENT CONTACT
The Phone and Email Patient Contact Register is designed to enable contact between patient or family / carer members with their permission. It lists Christian name, age, gender, suburb, postcode, state (not full postal address), phone / email address and original/current pituitary condition. You might like to be part of this Register. To request this list please contact the Chairperson. You may also like to join our members forums, please contact sue.pituitary@ozemail.com.au for more information.
Please check Yes and select either phone and/or email if you wish to be included on the Contact Register so that others may contact you. |
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| I consent to the collection and storage by the APF of health information which I have supplied above, and I am aware that I can at any time request details of any information collected and/or stored, and also the amendment or removal of any health information collected and/or stored on my behalf. |
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Instructions
Please note: All memberships are $30.00 AUD and are due for renewal at the end of the financial year (30th June). Please read our instructions by clicking here. This will open in a new window, you will not lose any information you have already entered into the form. |
| *Required |