Barrett's Esophagus 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: Has the client had any of the following treatments? Follow-up endoscopy(s) Surgery Please provide dates of follow-up endoscopy(s) or surgeries: Are any of the following present? (If yes, provide pathology report. Email to jrmosel@moseleymcgill.com) Dysplasia - low grade Dysplasia - high grade Metaplasia Is the client on any medications? If yes, provide details: Alcohol Usage? Type: Alcohol Usage? Frequency: 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