Chronic Obstructive Pulmonary Disease (COPD)

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Chronic Obstructive Pulmonary Disease (COPD) 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
Type of lung disease diagnosed:
- Asthma
- Emphysema
- Chronic Bronchitis
- Restrictive lung disease
- Other
If other, please describe:
Has the client ever been hospitalized for this condition?
- Yes
- No
If yes, provide date(s):
Date Format: MM slash DD slash YYYY
Has a pulmonary function test (breathing test) ever been done ?
- Yes
- No
If yes, provide most recent date and test results below:
Has a chest x-ray been done?
- Yes
- No
If yes, provide date and results:
Has an ECG been done recently?
- Yes
- No
If yes, provide date and results:
What is the client's height?
What is the client's weight?
Is the client using oxygen?
- Yes
- No
If yes, provide date(s):
Medications
Click 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:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) Questionnaire