Chronic Pain 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 UseType What medical condition or impairment is the source of the chronic pain?Date of onset: Date Format: MM slash DD slash YYYY If due to injury, describe how the client was injured and symptoms experienced as a result? Is narcotic pain medication taken?YesNoIf yes, advise name of the medication(s), dosage(s) and frequency taken: Is the client prescribed medical marijuana?YesNoIf yes, advise prescription details to include how much and how often it is used and method (smoked, ingested, drops, etc.) Has the client ever used more medication then what is prescribed?YesNoIf yes, provide details: Will the client be on narcotic pain medication long term or is this use temporary? Date Format: MM slash DD slash YYYY If temporary, when does he/she expect to be off medication? How often does the client see his/her doctor or pain management specialist? Is the client significantly impaired in a normal day-to-day activities?YesNoIf yes, advise what limitations the client has: Date Format: MM slash DD slash YYYY On a pain scale of 1 to 10, how does the client describe his/her level of pain. (1=very mild, 10=severe) 1 2 3 4 5 6 7 8 9 10 Does the client attend support groups and/or chronic pain rehabilitation program such as physical therapy or other?YesNoIf yes, provide details: What is the client's occupation?Is the client currently working?YesNoIs the client on Disability?YesNoIf yes, date he/she went on disability: Date Format: MM slash DD slash YYYY Is the disability going to be:PermanentTemporaryIf temporary, advise approximate duration of disability:Has the client ever had a history of anxiety, depression, or other mental health condition?YesNoIf yes, provide full details:Has the client ever had a history or drug or alcohol abuse?YesNoIf yes, provide full details:Does the client currently drink alcohol?YesNoIf yes, provide amount per sitting and frequency of use:Does the client use any recreational drugs?YesNoIf yes, advise type and frequency of use: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