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


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


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


   3.  How was the cancer treated ? (check all that apply)
        Surgery
        Chemotherapy
        Radiation Therapy


   4.  Date treatment was completed ?    


   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 of most recent AFP oir hCG test ?   


   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: heart disease, etc.)

       If yes, give details: