Moseleymcgill – Benign Prostatic Hypertrophy and Prostatitis

Benign Prostatic Hypertrophy and Prostatitis 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:
What condition has been diagnosed?
Result and Date of most recent PSA test:
Result and Date of most recent free PSA test:
Highest level PSA ever recorded (include date taken):
Has there been any kind of treatment?
- Yes
- No
If yes, provide date and description:
List any medications taken to treat the condition - list both current and past medications.
Click on the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
Date and results of the most recent digital rectal exam of the prostate:
Date and results of the most recent ultrasound of the prostate:
Date and results of the most recent prostate biopsy?
Has the client had surgery?
- Yes
- No
If yes, provide date and type:
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Benign Prostatic Hypertrophy and Prostatitis

Benign Prostatic Hypertrophy and Prostatitis Questionnaire