If your client has a sarcoidosis, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Was a biopsy done ?  Yes   No 

       Stage ? 


   3.  How was the sarcoid treated?
       no treatment
       prednisone


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  What organs were involved ?
        Lung
        Heart
        Liver or Spleen
        Eyes
        Kidney
        Central Nervous System
        Skin
        Lymph Nodes



   6.  Results of the most recent pulmonary function tests, if available :
       FVC  
       FEV1 


   7.  Has there been any evidence of recurrence/progression ? Yes   No 
       If yes, give details: 


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


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

       (example: cancer, etc.)

       If yes, give details: