If your client has a history of Chronic Lymphocytic Leukemia,
       please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What stage was the cancer ?
        Stage 0
        Stage I
        Stage II
        Stage III
        Stage IV


   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: