Blood Clots 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 Cause of blood clot: Atrial Fibrillation PFO (Patent Foramen Ovale) Travel ASD (Atrial Septal Defect) Sedentary Lifestyle Post-Operative Complication Other If Other, please describe: Clotting Disorder: Factor V Leiden Resistance Lupus Anticoagulant Antiphospholipid Antibody Other If Other, please describe: Date of first diagnosis: MM slash DD slash YYYY Type of treatment: Blood thinner (coumadin)? If yes, please provide date(s). Type of treatment: Aspirin? If yes, please provide date(s). Type of treatment: Hospitalization? If yes, please provide date(s). Any evidence of recurrence? Yes No If yes, provide dates/details: Have any of the following occurred due to blood clots? Heart attack Stroke Deep vein thrombosis (DVT) Pulmonary embolism Other If Other, please describe: MedicationsClick 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