Colitis and Crohn's Disease 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 Exact diagnosis: Colitis Chrohn's Disease Date of first diagnosis: Date Format: MM slash DD slash YYYY Date of most recent episode: Date Format: 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: Date Format: MM slash DD slash YYYY Result: Date of last Sigmoidoscopy: Date Format: 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?YesNoIf yes, provide details: Any complications? If yes, please provide details below: Has the client ever been hospitalized for the condition?YesNoIf yes, provide details: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