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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Type of glomerulonephritis ? 


   2.  Date of first diagnosis ? 


   3.  Was a kidney biopsy done ?
        Yes   (please give date and dignosis)
        No


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  Client's most recent reading for the following :
       Blood Pressure 
       BUN            
       Creatinine     
       Urinalysis     


   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: heart disease, etc.)

       If yes, give details: