If your client has had a spinal cord injury, please answer the following :

Agent Name:  
Client Name: 
Phone:  
Fax: 
   


1.  Date of injury ? 


2.  Injury was at what spinal cord level ?
       (list specific vertegrae, if available, i.e. C7-8)
       Cervical      
       Thoracic      
       Lumbrosacral  


3.  What is your client's current level of function ?
       Incomplete Paraplegia
       Complete Paraplegia
       Incomplete Quadriplegia
       Complete Quadriplegia


4.  Is your client on any medications ? Yes   No  If yes, give details:
 


5.  Have any of the following conditions ocurred ? (select all that apply)
       Pneumonia
       Skin Ulcers
       Urinary Tract Infection
       Kidney Impairment
       Depression

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

7.  Does your client have any major health problems ? Yes   No  (example: cancer, etc.)
If yes, give details: