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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What stage was the cancer ?
        Tis
        Ta
        T1
        T2
        T3a
        T3b
        T4


   3.  How was the cancer treated ? (check all that apply)
        Endoscopic Resection Only
        Endoscopic Resection & Chemotherapy Instilled in the Bladder
        Radical Cystectomy (removal of the bladder)
        Radiation Therapy
        Systemic Chemoptherapy


   4.  Date and result of the most recent cystoscopy ?  
   

   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


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

       If yes, give details: 


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


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

       (example: heart disease, etc.)

       If yes, give details: