Breast Cancer

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Breast 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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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 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?
- 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.
Relative Age of onset Age of death (if applicable)
Medications
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:
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

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Relative	Age of onset	Age of death (if applicable)

Breast Cancer

Breast Cancer Questionnaire