* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

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

1. Is it:

            Chronic bronchitis?             Emphysema?                      

            Asthma?                               Restrictive lung disease?  

2. Please list date first diagnosed?    

3. Please give details of your clients attacks?

            Mild       Moderate       Severe      

            Coughing of blood       Coughing of Phlegm  

4. Has your client ever experienced any of the following:

            Shortness of breath      Wheezing      Problems climbing stairs or exercising?  

            Other respiratory / lung problems?  

5. Have your client ever lost time from work?   Unknown Yes No

6. Has your client been hospitalized for this condition?  Unknown Yes No

7. Has your client ever smoked?   Yes No  

            If yes and currently smokes Amount per day?        

            If yes,  smoked in the past but quit list date quit?   

8. Is your client on any medications (include inhalers)?   Unknown Yes No   

            If yes, please explain:   .

9. Has a pulmonary test (a breathing test, TVC) ever been done?    Unknown Yes No

            If yes, what were the results (FEV)?  

10. Does your client have any abnormalities on an  EKG or X-ray?   Unknown Yes No

11. Does your client have any other  major health problems

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

            If yes, please explain: