* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

    *Sex?       Male Female

If your client has lupus or a connective tissue disease, please answer the following:

1. Indicate your clients actual diagnosis:

            Discoid Lupus        Systemic Lupus Erythematosus (SLE)  

            Sarcoidosis             Scleredema      Scleroderma  

            Other                  

2. When did your client first notice any symptoms?  

3. Please indicate dates and tests that have been completed to give your client this diagnosis?

            Date:       Test:   

            Results:   

            Date:       Test:  

            Results:   

            Date:       Test:   

            Results:   

4. Has your client had any of the following conditions?

            Low blood counts                               Proteinuria                                     

            Neurological disorder                        High blood pressure                      

            Heart involvement (pericarditis)       Renal insufficiency or failure    

            Lung involvement (pleuritis)          

5. Has your client been diagnosed with anemia in the past of

    currently?    Unknown Yes Currently Yes Past No

            If yes, please give details:  

6. Has your client gone into remission?   Unknown Yes No    How Long?  

7. Is your client under any treatment or has received any

    treatment in the past?   Unknown Yes Currently Yes Past No

            If yes, please give details:  

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

       If yes, please give details:  

9. Does your client have any other major health problems

    (example heart disease, etc)?    Unknown Yes No  

            If yes, please explain: