Anemia

Anemia 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
Type of Anemia:
- Sickle cell B0 or B+
- Sickle cell trait
- Sickle cell hgb C
- Iron deficiency
- Hemorrhagic
- Sideroblastic (Inherited)
- Sideroblastic (Acquired)
- Hemolytic (Inherited)
- Hemolytic (Acquired)
- Thalassemia
- Chronic Disease
Select any complications:
- Necrosis of bones
- Leg ulcers
- Lung scarring
- Blood clots
- Enlarged heart
- Kidney problem
- Blood transfusion
- Liver or spleen
Current hgb (hemoglobin)
Current hct (hematocrit)
Current rbc (red blood cells)
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken