Breast 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: MM slash DD slash YYYY Date of last treatment: MM slash DD slash YYYY Type of breast cancer: Ductal In-Situ Lobular Medullary Mucoid Tubular Stage of Cancer: Tis T0 T1mic T1a T1b T1c T1 T2 T3 T4 Grade: Grade 1 Grade 2 Grade 3 Grade 4 Did the lymph nodes test positive for cancer? Yes No If yes, how many? Was the cancer ER/PR positive? Yes No Check all that apply: Modified radical mastectomy Excisional biopsy (limited excision) Lumpectomy (wide excision) Partial mastectomy Chemotherapy Hormone therapy Radical mastectomy Radiation therapy Bone marrow transplant Any evidence of recurrence? Yes No If yes, provide details: Any family history of breast cancer? Yes No Family history details:Click on the + sign to add additional relatives. RelativeAge of onsetAge of death (if applicable) 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