If your client has proteinuria/albuminuria, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  How long has this abnormality been present ? 


   2.  Has a specific cause for the proteinuria been found ? Yes   No 

       If yes, give details: 

   3.  Date and results of the most recent unrinalysis :
       Protein                  
       Red Blood Cells (RBC's)  
       White Blood Cells (WBC's)
       Protein/Creatinine Ratio 


   4.  Date and results of the most recent kidney function tests :
       BUN              
       Serum Creatinine 


   5.  If any of the following unrinary test have been completed, please give date and results :
       Microalbumin       
       24-Hour Protein    
       24-Hour Creatinine 
       Other              


   6.  Is your client on any medication ? Yes   No 

       If yes, give details: 

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


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

       (example: cancer, etc.)

       If yes, give details: