Abdominal Aortic Aneurysm

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Abdominal Aortic Aneurysm Questionnaire
Please 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 Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has 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? Date Size
CAT Scan Date Size
Surgery Date
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

Ultrasound?	Date	Size

CAT Scan	Date	Size

Surgery	Date