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* 1. General Contact Information

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* 2. Date of Birth?

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* 3. How did you hear about CSRF?

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* 4. Please indicate which role best describes you.

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* 5. If you are a patient, or the parent of a pediatric patient, please share the source of your or your child's Cushing's.

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* 6. Date of diagnosis?

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* 7. Date of surgery, if applicable?

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* 8. Date of recurrence, if applicable?

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* 9. Months/years of remission, if applicable?

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* 10. Have you needed to take cortisol controlling medication?

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* 11. If yes on above question, please indicate which medication(s) apply.

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* 12. Clinical Trials: 

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* 13. If you have additional information or feedback regarding your experience with cortisol controlling medications, please share it here.

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* 14. Would you recommend your endocrinologist?

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* 15. If yes, please provide the name of the endocrinologist.

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* 16. Would you recommend your surgeon?

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* 17. If yes, please provide the name of the surgeon.

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* 18. Are you interested in sharing your patient story on our website or in a future issue of our Newsletter?

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* 19. Comments or feedback

Contact leslie@csrf.net for more information.
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