* 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 Colon / Colorectal Cancer, please answer the following:

1. Please list date of diagnosis:  

2. How was the cancer treated: 

            Surgery?    Unknown Yes No      

            Surgery plus chemotherapy and/or radiation?  

             Unknown Surgery Plus Chemotherapy Surgery Plus Radiation Surgery Plus Chemo and Radiation

3. Please list date treatment completed?  

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

        If yes, what medications?  

5. What stage was the cancer, please check proper box?

            Dukes' Stage A               Dukes' Stage B1 

            Dukes' Stage B2             Dukes' Stage C   

            Dukes' Stage D    

6. Has there been 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: