* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has had Breast Cancer, please answer the following:

1. Please list date of diagnosis:  

2. How was the cancer treated?

            Excisional biopsy only?   Yes No         Lumpectomy or wide excision?    Yes No

            Mastectomy?                   Yes No         Radiation Therapy?                      Yes No

            Chemotherapy?               Yes No         Hormonal Therapy? (tamoxifen)  Yes No

3. Please list date treatment completed:  

4. Is your client on any medications?   Unknown Yes No

            Please list?      

5. What Stage was the cancer?  

            Stage 0 (in-situ)            Stage I                 

            Stage II                         Stage III  

            Stage IV           

           Were there any lymph nodes involved?  Unknown Yes No    If yes, how many?  

6. Has there been any evidence of recurrence?   Unknown Yes No

            If yes, please explain:  

7. Does your client have any other major health problems

    (ex. Heart Disease, etc.)?   Unknown Yes No

        If yes, please explain:    

If possible, please obtain the pathology report of the breast cancer.