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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseTypeDate of diagnosis: Date Format: MM slash DD slash YYYY Date of last treatment: Date Format: 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?YesNoIf yes, provide details:Any family history of breast cancer?YesNoFamily 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