If your client has a history of Hairy Cell Leukemia, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  How was the cancer treated ? (check all that apply)
        Close Observation Only
        Splenectomy
        Interferon
        2-cdA
        Pentostatin
        Bone Marrow Transplant
        Other, Please Specify: 


   3.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   4.  Results of most recent CBC (complete blood count) ?

       Date: 

       Hemoglobin: 

       White Blood Cell Count: 

       Platelet Count: 


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


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

       (example: heart disease, etc.)

       If yes, give details: