If your client has a history of anxiety disorders, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Diagnosis ?
       Generalized Anxiety Disorder
       Obsessive Compulsive Disorder
       Agoraphobia
       Panic Disorder
       Post-Traumatic Stress Disorder
       Other, give details 


   2.  Number of episodes ? 

       Date of last episode/recovery ? 


   3.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   4.  Has your client been hospiltalized or seen in the emergency room for treatment
       of anxiety or other psychiatric illness ? Yes   No 

       If yes, give details: 


   5.  Does your client have a history of any of the following associated conditions ?
        Depression
        Substance Abuse (alcohol or drugs)
        Suicidal Thought/Attempt
        Other Psychiatric Disorder



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


   7.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: