If your client has a history of Endrometrial (Uterine) cancer, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What stage was the cancer ?
        Stage 0 (in-situ)
        Stage I
        Stage II
        Stage III
        Stage IV


   3.  How was the cancer treated ? (check all that apply)
        Total Hysterectomy
        Radiation Therapy
        Chemotherapy
        Hormonal Therapy
        Cone Surgery

   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: