* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has cerebral and neurological  problems, please answer the following:

1. Indicate what your client has been diagnosed with:

            Amnesia                         Transient Ischemic Attack (TIA)  

            Stroke (CVA)               Organic Brain Syndrome               

            Tremor                          Parkinson's Disease                     

            Dementia                      Alzheimer's Disease                     

            Other, please explain:  

2. Please give date   and occurrence(s)

3. Have any special tests or studies been done

    (i.e. CAT scan, MRI, Stress Test)? Unknown Yes No

4. Has your client required any special assistance on a regular basis?    Unknown Yes No

5. Is your client fully recovered?  Unknown Yes No

                Please   give details:  

6. Does your client have any other Major Health Problems

    (i.e. cancer, heart, etc.)? Unknown Yes No

            If yes, please give details:  

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

           If yes, please give details:  

8. Does your client smoke cigarettes?   Yes No