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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Has your client ever been hospitalized for this condition ?
       Yes
       No

       If yes, give details: 


   3.  Has you client ever smoked ?
        Yes, and currently smokes  (amount/day)
        Yes, smoked in the past but quit  (date)
       No

       If yes, give details: 


   4.  Is your client on any medication ? (including inhalers) Yes   No 

       If yes, give details: 


   5.  Have pulmonary function tests (a breathing test) ever been done ?
        Yes, give most recent test results 
        No


   6.  Does your client have any abnormalities on an EC G or x-ray ?
        Yes, give details 
        No


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

       (example: cancer, etc.)

       If yes, give details: