Asthma 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 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 staySpecial circumstances What medications are being used to control asthmatic attacks?Click the + sign to add additional medications.Name of medication (prescription or otherwise)Dates usedQuantity takenFrequency taken List any abnormal EKG, chest x-ray, or pulmonary function testing: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