* 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 ulcerative colitis / crohn's disease, please answer the following:

1. Date of first symptoms?      Date of last attack?  

            How often does your client have attacks? 

            Are the attacks becoming more frequent?  Unknown Yes No

2. Date  of diagnosis? 

3. How was it diagnosed?

            By history?         By x-ray studies?        By biopsy of bowel?  

4. Current Medications?  

            If on steroids, type?      Dosage?  

            How long on Steroids?  

5.  Any Surgery?   Unknown Yes No       When?  

           If yes, please explain results:  

6. Does your client have any other major health problems

    (ex. heart, cancer, etc.)?   Unknown Yes No   

            If yes, please give details: