* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

      *Sex?     Male Female

If your client has had prostate cancer, please answer the following:

1. Please list the date of diagnosis?  

2. How was the cancer treated?

            Observation only?                                 Unknown Yes No

            TURO (transuethal prostatectomy)?   Unknown Yes No

            Radical prostatectomy?                        Unknown Yes No

            Radiation therapy?                               Unknown Yes No

            Hormone therapy?                                Unknown Yes No

            Last date of treatment:                         

3. Is your client on medications?   Unknown Yes No

            If yes, please explain:  

4. What stage was the cancer?

            A1             B1             C            A2            B2            D  

5. What was the Gleaseon score?   2-5              6-10    

6. Has there been evidence of recurrence?   Unknown Yes No

           If yes, please explain: 

7. Please give the date and result of the most recent PSA test?

            Date?       Result?   

8. Does your client have nay other major health problems 

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

            If yes, please explain: