Acromunity Medical Details and Treatment Tracker

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Acromunity Medical Details and Treatment Tracker This document is intended to help you keep a record of important details that you may need to share with healthcare professionals throughout your journey living with acromegaly, particularly when you are first diagnosed. Take a copy with you to your various appointments and ask your healthcare professionals to help you complete it. About You Write down your name and contact details here and the name and phone number of someone to contact in an emergency such as a family member or close friend. First Name: Last Name: Date of Birth: Phone: Emergency Contact: (Name/Phone Number) Notes

Your Acromegaly History Make a note of your acromegaly history here, such as the date you were first diagnose and who made the diagnosis, and any symptoms you were experiencing. Ask your healthcare team to help you fill in this section if needed. Date of Your Diagnosis (day, month, year): Who Made the Diagnosis? [ ] Primary care doctor [ ] Endocrinologist [ ] Other. What were (are) your symptoms: Other information about your acromegaly:

Your Tests and Results Keep a record of any tests or procedures that you may have had here. Ask a member of your healthcare team to help you complete this section and to keep it updated. Date of test Test name (e.g. MRI scan. IGF-1 blood test) Result of test

Your Treatment Plan Ask a member of your healthcare team to help you complete this section and make a note of the treatments you have or will receive. Treatment Goal: Treatments Received: Surgery Radiation Therapy Medication Date of surgery: Type of surgery: Location of surgery: Outcome of surgery: Type of radiation therapy: Dose and radiation schedule: Date of first treatment: Date of last treatment: Outcome of radiation therapy: Name of medication: Dose and frequency: Date of first treatment: Date of last treatment: Outcome of medical therapy: Other treatments received for acromegaly:

Your Symptoms and Side Effects Log any symptoms or side effects that you may have experienced here. Remember to tell a member of your healthcare team about any side effects you may be experiencing. Note the date and time(s) if you remember. Date Time Symptom/side effect How bothersome was it on a scale of 1 (not at all) to 10 (very)?

Your Healthcare Professionals Write down the names and contact details of the healthcare professionals in your multidisciplinary team here, such as the name of your primary care doctor and nurse, endocrinologist and others who are involved in your care. Primary care doctor Name: Practice address: Telephone: Endocrine nurse: Clinic or hospital address: Telephone: Endocrinologist Doctor s name: Clinic or hospital address: Telephone: Other Doctor s name: Clinic or hospital address: Telephone:

Your General Health Make a note of your general health and any other specific health issues here, such as if you are allergic to a particular medication or have been diagnosed with other medical conditions such as high blood pressure, high cholesterol, asthma or diabetes. Do you have any allergies? Describe any allergies you may have here (e.g., allergic to penicillin) Other than acromegaly, do you have any other longterm medical conditions for which you receive treatment? List any medications you may be taking here [ ] Yes [ ] No [ ] Don t know [ ] Anxiety [ ] Arthritis [ ] Asthma [ ] Chronic obstructive pulmonary disease (COPD) [ ] Diabetes [ ] Depression [ ] Heart disease [ ] Irritable bowl syndrome (IBS) or inflammatory bowel disease (e.g. ulcerative colitis, Crohn s disease) [ ] Other, please specify.. Name of medication Reason.. Dose and frequency. Name of medication Reason.. Dose and frequency. Name of medication Reason.. Dose and frequency.

How tall are you? What is your current weight? [ ] meters and [ ] cm or [ ] Feet [ ] inches [ ] Kg or [ ] stones and [ ] pounds Other (list any other information you think might be important here): Your Notes Make any additional notes here, such as any questions you would like to ask at your next appointment or any concerns that you may have regarding living with acromegaly.

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