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Requested Illustration:

1. PLEASE LIST THE DATE OF THE FIRST DIAGNOSIS:

2. IS THE CLIENT ON ANY MEDICATIONS FOR THE DISEASE?
Yes No IF YES, PLEASE DETAIL

3. HAS YOUR CLIENT EXPERIENCED ANY OF THE FOLLOWING 
WEIGHT LOSS
FEVER
LOW BLOOD COUNTS
HEART DISEASE
LUNG DISEASE
LIVER ENZYME ABNORMALITY
KIDNEY DISEASE

4. PLEASE LIST FUNCTIONAL ABILITY:
FULLY ACTIVE
SEDENTARY
USES WALKER, CANE, ETC.
USES WHEELCHAIR

5. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
Yes No IF YES, PLEASE DETAIL

6. CLIENT'S OCCUPATION FULL TIME PART TIME

7. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

8. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: