Alcohol Use 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 UseTypeDoes the client use alcohol?YesNoIf no, date of last alcohol use:QuantityBeerWineLiquorHow often?In the past, did the client drink substantially more than now? If yes, provide details below.YesNoQuantityBeerWineLiquorHow often?Has the client ever been treated for excessive alcohol use?YesNoIf yes, provide details below, including dates:Has the client ever been arrested for driving under the influence (DUI) or for driving while intoxicated (DWI)?YesNoIf yes, provide details below, including dates:Does the client attend AA or similar?YesNoIf yes, how often?Is the client taking or has the client ever been prescribed Antabuse or any other medication to control his/her drinking? If yes, provide name of medication and details: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