Attention Deficit Disorder

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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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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:
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

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Attention Deficit Disorder

Attention Deficit Disorder Questionnaire