Colitis and Crohn’s Disease

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Colitis and Crohn's Disease 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 diagnosis:
- Colitis
- Chrohn's Disease
Date of first diagnosis:
MM slash DD slash YYYY
Date of most recent episode:
MM slash DD slash YYYY
Total number of episodes:
Number of episodes in past 6 months:
Longest duration (days, weeks, months):
Number of episodes in past 5 years:
Longest duration (days, weeks, months):
What conditions have been diagnosed?
- Irritable bowel syndrome
- Frequent colon spasms
- Frequent diarrhea
- Ulcerative proctitis
- Mucous colitis
- Spastic colitis
- Catarrhal colitis
- Ulcerative proctosigmoiditis
- Chronic proctitis (rectum)
- Chronic ulcerative colitis
- Crohn's disease
- Ischemic colitis
- Other
If other, please describe:
Is the diagnosis considered
- Mild
- Moderate
- Severe
Date of last Colonoscopy:
MM slash DD slash YYYY
Result:
Date of last Sigmoidoscopy:
MM slash DD slash YYYY
Result:
Any significant effect on day-to-day functionality or any time lost from work as a result of the condition?
- Yes
- No
If yes, provide details:
Any complications? If yes, please provide details below:
Has the client ever been hospitalized for the condition?
- Yes
- No
If yes, provide details:

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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Colitis and Crohn’s Disease

Colitis and Crohn's Disease Questionnaire