Barrett's Esophagus

Barrett's Esophagus 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
MM slash DD slash YYYY
Client Name
Date of Birth
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:
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:
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