If your client has a history of Rheumatoid Arthritis, please answer the following :


Agent Name:  
Client Name: 
Phone:  
Fax: 
   

1.  Date of first diagnosis ? 

2.  Is your client on any medication ? Yes   No If yes, give details: 


3.  Has your client had any of the following ?
       Weight Loss
       Fever
       Low Blood Counts
       Heart Disease
       Lung Disease
       Liver Enzyme Abnormality
       Kidney Disease

4.  What is your client's current functionability ?
       Fully Active
       Sedentary
       Uses Walker, Cane, etc.
       Uses Wheelchair

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: cancer, etc.)
 If yes, give details: