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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseTypeDate of initial diagnosisHas the client had any of the following:Ultrasound?DateSize CAT ScanDateSize SurgeryDate Has the aneurysm been stable in size for two or more years?YesNoProvide details:Is your client on any medications?YesNoProvide 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