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


Agent Name:  
Client Name: 
Phone:  
Fax: 
   

1.  Date of first diagnosis ? 
2.  Number of episodes ? Date of last episode/recovery ? 


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



 4.  Current neurological status and/or symptoms ?
       Normal
       Minimal Residual Impairment, specify   
       Moderate Residual Impairment, specify  
       Severe Residual Impairment, specify    


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: