If your client has a history of Ulcerative Colitis or Crohn' Disease, please answer the following:


Agent Name:  
Client Name: 
Phone:  
Fax: 
   
1.  Date of first diagnosis ?  

2.  Type of inflammatory bowel disease present ?
        Chronic Ulcerative Colitis
        Chronic Proctitis (inflammation in rectum only)
        Crohn's Disease

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


 4.  Has your client had ?
        Hospitalizations for this disorder? Date(s) 
		 Surgery for this disorder? Date(s) 


5.  Date treatment was completed ?    

6.  Client's build ?
       Height Weight 

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: heart disease, etc.)
If yes, give details: