Bladder Cancer

Bladder Cancer 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:
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 Used	Quantity Taken	Frequency Taken

List any other major health problems the client has:
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