Moseleymcgill – Attention Deficit Disorder

Attention Deficit Disorder 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

Client Name

Date of Birth

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:

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:

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