Cancer Questionnaire

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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
MM slash DD slash YYYY
Client Name
Date of Birth
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
Exact name of the cancer:
Date of diagnosis:
MM slash DD slash YYYY
Date of last treatment:
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?
- Yes
- No
If yes, provide details:

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:
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