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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What stage was the cancer ?
        A1
        A2
        B1
        B2
        C
        D


   3.  What was the Gleason Score ?   


   4.  How was the cancer treated ? (check all that apply)
        Observation Only
        TURP (transurethral prostatectomy)
        Radical Prostatectomy
        Radiation Therapy
        Hormonal Therapy


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   6.  Has there been any evidence of recurrence ? Yes   No 

       If yes, give details: 


   7.  Date and result of the most recent PSA test ?     


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

       (example: heart disease, etc.)

       If yes, give details: