Asthma

Asthma 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
MM slash DD slash YYYY
Client Name
Date of Birth
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 Diagnosis:
Type of asthma diagnosed:
What leads to asthmatic attacks?
When did attacks occur?
- During past year
- During past 2 years
Number of attacks per year (state if continuous):
If the client has been hospitalized or had ER visits due to severe asthma attacks, complete the information below:
Click the + sign to add additional hospitalizations/ER visits.
Date(s) of hospitalization/ER visits(s) Length of hospital stay Special circumstances
What medications are being used to control asthmatic attacks?
Click the + sign to add additional medications.
Name of medication (prescription or otherwise) Dates used Quantity taken Frequency taken
List any abnormal EKG, chest x-ray, or pulmonary function testing:
List any other major health problems the client has:
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Date(s) of hospitalization/ER visits(s)	Length of hospital stay	Special circumstances

Name of medication (prescription or otherwise)	Dates used	Quantity taken	Frequency taken