Attention Deficit Disorder 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: Is the client on any medications? Yes No If yes, provide details: Does the client have a history of any of the following psychiatric disorders? Mood or anxiety disorder Personality disorder Conduct disorder or oppositional disorder Suicidal thought/attempt Substance abuse (alcohol or drugs) Other If other, please describe: Has the client ever been hospitalized or on disability for psychiatric treatment? Yes No If yes, provide details: If school-age, is the client in regular class for age? Yes No If yes, provide 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 © 2017 Tellus Brokerage Connections Δ