Autism 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: Does the client live independently? Yes No Currently working? Yes No Select the option that best describes the autism: Asperger’s syndrome/High functioning (IQ above 70, None or very minimal impairment in sensorimotor ability, well developed language skills) Mild (IQ 50-70, minimal impairment in sensorimotor ability, ability to acquire grade school academic skills, vocational skills for selfsupport may be achieved, may need assistance or guidance if stressed but may also be able to live independently or with limited supervision) Moderate (IQ 35-49, able to acquire some communication skills with training, academic skills limited to early grade school level, social skills significantly impaired but may be able to perform unskilled or semi-skilled labor under supervision) Severe (Poor motor development, minimal speech and little or no communication skills, not able to live independently) Profound (IQ < 20, none to minimal speech and communication skills, need to live in a closely supervised environment) History of seizures? Yes No If yes, please specify the type of seizure: Grand mal Petit mal Partial seizure-complex Focal Symptoms experienced with seizures (select all that apply): Unconsciousness Clouded consciousness Uncontrolled twitching Deep sleep Other If other symptoms, provide details: Frequency of seizures: Date of last seizure: MM slash DD slash YYYY Any associated mental health or behavioral disorder (e.g. obsessive compulsive disorder, anxiety, panic attacks, depression or other) If yes, provide details:MedicationsClick the + sign to add additional medications.Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken 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