Chronic Obstructive Pulmonary Disease (COPD) 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 MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type Date of diagnosis: 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): 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): MedicationsClick 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 Δ