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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  What organs are involved ? (check all that apply)
        Liver
        Pancreas (Diabetes)
        Joints
        Heart
        Pituitary


   3.  When was the last phlebotomy treatment ? 


   4.  If available, provide the most recent serum ferritin result ? 


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   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: cancer, etc.)

       If yes, give details: