Abdominal Aortic Aneurysm QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name* Phone* Email* Date MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type Date of initial diagnosis Has the client had any of the following:Ultrasound?DateSize CAT ScanDateSize SurgeryDate Has the aneurysm been stable in size for two or more years? Yes No Provide details: Is your client on any medications? Yes No Provide details: Are any of the following present? Check all that apply: Pain in the legs with walking Hypertension Coronary artery disease Elevated cholesterol Diabetes Cerebrovascular List any other major health problems the client has: For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2016 Tellus Brokerage Connections Δ