Benign Prostatic Hypertrophy and Prostatitis 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseTypeDate 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 UsedQuantity TakenFrequency 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: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