* 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 testicular cancer, please answer the following:

1. Please list date of diagnosis? 

2. How was the cancer Treated? (check all that apply)

            Surgery?         Chemotherapy?      Radiation therapy?  

3. Please list date treatment completed?  

4. Is your client on medications?   Unknown Yes No

            If yes, please explain:  

5. What stage was the cancer?

            Stage I          Stage II        Stage III    

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

           If yes, please explain:  

7. Please give the date and the result of the most recent AFP or hCG test?  

            Date?      

            Results?   

8. Has your client smoked cigarettes in the last 12 months?    Yes No

9. Does your client have any other major health problems?  Unknown Yes No

           If yes, please explain: