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Requested Illustration:

1. PLEASE DETAIL THE CLIENT'S MEDICAL HISTORY:
FATHER'S AGE IF LIVING  
OR AT THE TIME OF DEATH AND CAUSE OF

MOTHER'S AGE IF LIVING  
OR AT THE TIME OF DEATH AND CAUSE OF

SIBLING'S AGE IF LIVING  
OR AT THE TIME OF DEATH AND CAUSE OF

2. DETAIL THE CLIENT'S MEDICAL HISTORY (CHECK ANY APPLICABLE)
CANCER HISTORY 
HEART HISTORY / CONDITION
DIABETES HISTORY 
ALCOHOL OR DRUG ABUSE HISTORY
HIGH BLOOD PRESSURE,
    IF YES, PLEASE DETAIL:
    CURRENT READING
    HDL READING OR RATIO
    TYPE OF TREATMENT

ELEVATED CHOLESTEROL HISTORY, IF YES, PLEASE DETAIL:
    CURRENT READING
    HDL READING OR RATIO
    TYPE OF TREATMENT

ELECTROCARDIOGRAM (EKG), IF TAKEN WITHIN THE LAST YEAR: RESULTS:
NORMAL, OTHER

STRESS EKG OR THALLIUM, IF TAKEN WITHIN PAST LAST YEAR: RESULTS:
NORMAL, OTHER

SIGMOIDOSCOPY IF TAKEN WITHIN PAST YEAR, DETAIL:
LAST YEAR: RESULTS: NORMAL, OTHER

PROSTATE EXAM, IF TAKEN WITHIN THE PAST YEAR, 
LAST YEAR: RESULTS: NORMAL, OTHER

MAMMOGRAM, IF TAKEN WITHIN THE PAST YEAR, 
LAST YEAR: RESULTS: NORMAL, OTHER

3. HAS THE CLIENT HAD A STANDARD CHECKUP WITHIN THE LAST YEAR? Yes No
IF YES, DETAIL DATE AND RESULTS:

4. CLIENT'S MARITAL STATUS: Single Married Divorced Widowed

5. DOES THE CLIENT CURRENTLY TAKE ANY MEDICATION? WHAT TREATMENT IS CURRENTLY BEING PRESCRIBED? Yes No
IF YES, DETAIL DATE AND RESULTS:

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

7. DOES THE CLIENT TAKE VITAMINS? Yes No
IF YES, PLEASE DETAIL

8. HAS THE CLIENT RECEIVED ANY DRIVING VIOLATIONS DURING THE PAST THREE YEARS? Yes No
IF YES, PLEASE DETAIL DATE & TYPE

9. DOES THE CLIENT PARTICIPATE IN AVIATION / AVOCATION ACTIVITIES? Yes No
IF YES, PLEASE DETAIL DATE & TYPE

10. CLIENT'S OCCUPATION FULL TIME PART TIME

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