Anemia 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 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 UsedQuantity TakenFrequency Taken Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken 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 © 2017 Tellus Brokerage Connections Δ