Chronic Pain

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Chronic Pain 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
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?
- Yes
- No
If yes, advise name of the medication(s), dosage(s) and frequency taken:
Is the client prescribed medical marijuana?
- Yes
- No
If 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?
- Yes
- No
If 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?
- Yes
- No
If 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?
- Yes
- No
If yes, provide details:
What is the client's occupation?
Is the client currently working?
- Yes
- No
Is the client on Disability?
- Yes
- No
If yes, date he/she went on disability:
Date Format: MM slash DD slash YYYY
Is the disability going to be:
- Permanent
- Temporary
If temporary, advise approximate duration of disability:
Has the client ever had a history of anxiety, depression, or other mental health condition?
- Yes
- No
If yes, provide full details:
Has the client ever had a history or drug or alcohol abuse?
- Yes
- No
If yes, provide full details:
Does the client currently drink alcohol?
- Yes
- No
If yes, provide amount per sitting and frequency of use:
Does the client use any recreational drugs?
- Yes
- No
If yes, advise type and frequency of use:
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:
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

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Chronic Pain

Chronic Pain Questionnaire