* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    Height?       Weight?    

If your client is age 70 and over, please answer the following:

1. Sex?   Male Female   Date of birth?  

2. Describe your clients current marital status:   Married Single Widowed Divorced

           If spouse is diseased, date of death?  

3. Please describe your clients living arraignment?   Live alone Live with spouse Live with other family members Live in a retirement facility Confined to a full care facility

4. What type of regular exercise does your client get, if any (ex. gardening, walking, swimming, etc.)?

            Please explain:  

5. What is your clients height?      Weight?  

6. Has your clients weight changed by ten pounds or more in the past 12 months?    Unknown Yes No

            If yes, please give details?  

7. Does your client see a regular physician?   Unknown Yes No

8. Does your client see other doctors?   Unknown Yes No  

            If yes, please explain:  

9. When did your client have a complete medical examination?   Date:   

10 Has your client been hospitalized in the last five years?   Unknown Yes No

           If yes, please give details:  

11. does your client do their own grocery shopping?  Unknown Yes No

12. If your client is retired, is he capable of working?    Unknown Yes No

13.  Does your client have any major health problems (ex. cancer, heart etc.)?   Unknown Yes No

            If yes, please give details: