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

Agent Name:  
Client Name: 
Phone:  
Fax: 

1.  Date of first diagnosis ? 


2.  Type of lupus diagnosed ?
       Systemic Lupus Erythematosus (SLE)
       Discoid Lupus
       Drug Induced SLE


3.  Is your client on any medications ? Yes   No 

       If yes, give details:  


4.  Is lupus ?
       In Remission, date of last exacerbation 
       Currently Present

5.  Has your client had any of the following conditions ? (select all that apply)
       Low Blood Counts
       Lung Involvement (pleuritis)
       High Blood Pressure
       Proteinuria
       Neurologic Disorder
       Heart Involvement (pericarditis)
       Renal Insufficiency or failure

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: