* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has imunodeficency, please answer the following:

1. What was the actual diagnosis?  

2. When was your client first diagnosed?  

3. What were your clients symptoms?  

4. Please indicate dates and tests that have been completed to give your client this diagnosis?

            Date:           Test:   

            Results:   

            Date:           Test:  

            Results:   

            Date:           Test:   

            Results:   

5. Has your client ever had any blood transfusions?   Unknown Yes No  

           If yes, please give details and dates:  

6. Has your client ever tested positive for HIV?   Unknown Yes No

7. What symptoms did your client have to cause him/her to be tested?

8. Has your client ever been told that they have or  had an STD, AIDS or AIDS related condition?

            Unknown Yes No

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

            If yes, please give details:  

10. Does your client have any other major health problems

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

            If yes, please give details: