* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has kidney disease, please answer the following:

1. Date first diagnoses?      What was the actual diagnosis?  

            What were your clients first symptoms?  

            Was/is there blood in your clients urine?   Unknown Yes No

            Has your client ever had kidney stones?   Unknown Yes No

            Has your client ever had kidney failure?   Unknown Yes No

2. Dates of most recent laboratory evaluation, and their results?:

            BUN date?       Results?    

            Creatinine date?       Results?     

            24 hour creatinine clearance?      Results?   

            24 hour protein loss?    Results? 

            Urinalysis Specimens protein loss?      Results? 

3. If kidney transplanted, date surgery was done?  

            What disease caused the need for a transplant?  

            Was the donor related?   N/A Yes No

            Current medications? 

4. Does your client have any other major health problems

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

            If yes, please explain?