* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has liver problems, please answer the following:

1. Date of the diagnosis?  

2. What was your clients first symptoms?  

3. Please indicate the dates and tests that have been completed to give your

    client this diagnosis? 

4. Please list your current liver function tests, if known?

            AST/SGOT date?       Results?   

            ALT/SGPT date?        Result?   

            GGPT date?                Result?    

5. Has your client ever been diagnosed with any of the following?

            If checked, complete the additional relative questionnaire(s).

            Hepatitis         Crohns      Ulcerative colitis    

            Alcoholism      Drugs    

6. Has your client ever had a gall  bladder problem?   Unknown Yes No

7. Has your client ever had any surgeries?  Unknown Yes No

           If yes, please give details and dates of surgeries:  

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

           If yes, please list medications and dosages:  

9. Date you last consulted your physician?  

10 Does your client Smoke Cigarettes?   Yes No

11. Does your client have any other major health problems

(ex. cancer, heart)?    Unknown Yes No

            If yes, please explain: