* 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 Cancer, please answer the following:

1. What type of cancer and where was it found, please explain: 

2. When was it diagnosed?     What was the stage?     

            What was the grade? 

3. What type of treatment:

            Surgery?    Unknown Yes No   Date? 

            Please explain?  

            Chemotherapy?    Unknown Yes No    Date last treatment?  

            Radiation?            Unknown Yes No    Date last treatment?    

4. Had the cancer spread beyond the original site or were the lymph

    nodes involved?  Unknown Yes No

                        If Yes, please explain:  

5. When was the last follow up to the clients physician and what were the results:

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

           If yes, please explain:  

6. If the cancer was Prostate, what was the PSA prior to treatment?   

            Current PSA reading?      Gleason Score?  

7. Does your client smoke cigarettes?   Yes No

8. Does your client have any other major health problems

    (ex. Heart, Diabetes, etc.)?    unknown Yes No   

             Please explain:  

Please submit any documented report if possible (ex. pathology).