CSRF Membership Form

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* 1. General Contact Information

Name *

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number

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* 2. Date of Birth?

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* 3. How did you hear about CSRF?

Internet search

Doctor referral

Fellow patient

Other (please specify)

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* 4. Please indicate which role best describes you.

Patient

Caregiver

Parent

Other family

Friend

Doctor

Other (please specify)

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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.

Pituitary

Adrenal

Ectopic

Suspicion only, no testing yet

Still in the process of diagnosis

Other (please specify)

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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?

Yes, in the past, but no longer

Yes, currently taking

Currently being prescribed

Offered, but declined

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

cabergoline

pasireotide (Signifor)

mifepristone (Korlym)

ketoconazole

metyrapone (Metopirone)

osilodrostat (Isturisa)

mitotane (Lysodren)

etomidate

Other (please specify)

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* 12. Clinical Trials:

I participated in a clinical trial in the past, but not now

I am currently enrolled in a clinical trial

I have been offered a trial, but declined

I have never been offered a clinical trial, but would consider participating in one

I know little to nothing about clinical trials

Other (please specify)

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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?

Yes

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

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* 16. Would you recommend your surgeon?

Yes

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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?

Yes, please contact me

No, not at this time

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* 19. Comments or feedback

Contact leslie@csrf.net for more information.