* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has Hepatitis, please answer the following:

1. Please list the diagnosis:  

2. Was the hepatitis due to:

            Hepatitis A                  No Yes       Hepatitis B Resolved   No Yes

            Hepatitis B Carrier     No Yes       Hepatitis C                    No Yes

            Other, please specify:  

3. Please give the date and results of the most recent liver enzyme tests:

            AST/SGOT date:       Results:  

            ALT/SGPT date:       Results:  

            GGTP date:               Results:    

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

            Please list medications:  

5. Does your client drink alcohol?   Unknown Yes No

            If yes, please give details:  

6. Has any of the following studies been done?

            Liver ultrasound or CT scan?   Unknown No Yes Abnormal Yes Normal

            Liver biopsy?                             Unknown No Yes Abnormal Yes Normal

            No further evaluations?             Unknown Yes No

            Explain:  

7. Has your client been diagnosed with any of the following?

            Chronic persistent hepatitis?   Unknown Yes No

            Chronic Active Hepatitis?        Unknown Yes No

            Cirrhosis?                                  Unknown Yes No

8. Does your client have any other major health problems

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

            If yes, please explain: