* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has multiple Sclerosis, please answer the following:

1. Please list date of first diagnosis?  

2. Please indicate the number of episodes and the date of the last episode?

            Number?       Date of last episode?  

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

           If yes, please list medications:  

4. Please  note current neurologic status and/or symptoms?

            Normal?    Unknown Yes No

            Minimal residual impairment, please explain:  

            Moderate residual impairment, please explain:  

            Severe residual impairment:  

5. Has your client smoked cigarettes in the last 12 months?   Yes No

6. Does your client have any other major health problems

    (ex. heart disease, stroke, cancer?   Unknown Yes No   

             If yes, please explain: