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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What stage was the cancer ?
        in-situ
        Dukes' Stage A
        Dukes' Stage B1
        Dukes' Stage B2
        Dukes' Stage C
        Dukes' Stage D


   3.  How was the cancer treated ? (check all that apply)
        Surgery
        Surgery plus Chemotherapy and/or Radiation


   4.  Date treatment was completed ?  
   

   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: