Brain Tumor 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: MM slash DD slash YYYY Date of last treatment: MM slash DD slash YYYY Type of tumor: Glioma Astrocytoma Meningioma Oligodendroglioma Medulloblastoma Pineoblastoma Pineocytoma Sarcoma Schwannoma Stage: I II III IV Treatment Surgical resection Radiotherapy Radiation Radioactive implants Describe any limitations in physical or cognitive function.Describe any additional treatment for complications (e.g. seizures).Describe any evidence of recurrence.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