* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has peripheral vascular disease / neuropathy, please answer the following:

1. Has your client been diagnosed with any of the following:

            Peripheral vascular disease                    Leiche's Syndrome   

            ASO (Arterio Sclerosis Obliterans)        Claudication             

            Aneurysm:   Abdominal       Vascular       Cerebral   

            Other disorder of the circulatory system     

            Please describe:   

2. When was your client diagnosed?  

3. What were your first 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. Have any of the following surgeries been suggested or done?

            Aorto Femoral Bypass (Leg Vessels)             Date?  

            Endarterectomy (clean arteries)                     Date?      

            Aneurysmotomy (repair of an aneurysm)       Date?  

            Other surgical procedure, details:     

            Date?  

6. What were the results of the surgery(ies)?  

7. Does your client have any other major health problems

    (ex. cancer, heart)?    Unknown Yes No

            If yes, please give details:  

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

            If yes, please give details: