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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Was the hepatitis due to ?
        Hepatitis A
        Hepatitis B, Resolved
        Hepatitis B, Carrier
        Hepatitis C (non-A/non-B)
        Other, please specify


   3.  Date and results of the most recent liver enzyme tests :
       AST/SGOT: 
       ALT/SGPT: 
       GGTP:     


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  Does your client drink alcohol ? Yes   No 


   6.  Check if the following studies have been completed ?
       Liver Ultrasound or CT Scan    Yes   No 
       Liver Biopsy                   Yes   No 
       No Further Evaluation         


   7.  Check if your client been diagnosed with any of the following :
        Chronic Hepatitis
        Cirrhosis


   8.  Has your client been treated with interferon ? Yes   No 

       If yes, give details: 


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


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

       (example: cancer, etc.)

       If yes, give details: