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 UseTypeExact name of the cancer:Date of diagnosis: Date Format: MM slash DD slash YYYY Date of last treatment: Date Format: MM slash DD slash YYYY How has the cancer been treated? Surgery Radiation Chemotherapy Hormone therapy Immunotherapy Observation only Other If other treatment, please describe:Grade: I II III IV Other If other Grade, please describe:Stage of Cancer: I II III IV Other If other Stage, please describe:Any evidence of recurrence?YesNoIf yes, provide details: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:If at all possible, please obtain the pathology report. It will enable us to work with you prior to a formal application to determine if coverage is now available, at which insurance company, and for what likely premium.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