Bladder Cancer 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: Date of last treatment: Type of bladder cancer diagnosed: Adenocarcinoma Benign papilloma Papillary hyperplasia Squamous cell carcinoma Transitional cell carcinoma Stage of cancer: Stage I Stage II Stage IIIA Stage IV Stage 0 Stage A Stage B1 Stage B2 Stage C Stage D1 Stage D2 Tis TIN0M0 T2N0M0 T3N0M0 T3BN0M0 T4N1-3M0-1 If the cancer was graded, select the grade assigned: Grade I Grade II Grade III Grade IV Has the cancer been treated? (select all that apply) Radical cystectomy (removal of bladder) Immunotherapy/biological therapy Radiation therapy Photodynamic therapy Chemotherapy Endoscopic resection Has there been any evidence of recurrence? Yes No If yes, provide details: List all current medications being taken for any reason:Click on 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