Colorectal Cancer 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 Date of first diagnosis: Date Format: MM slash DD slash YYYY Date of last diagnosis: Date Format: MM slash DD slash YYYY Stage and grade of cancer: 0 (In Situ) 1 (T1 NO MO) 1 (T2 NO MO) 2A (T3 NO MO) 2B (T4 NO MO) 3A, 3B (T1, 2 or T3,4, N1, MO) 3C, 4 (T any, N2, or M1) Other staging system used:Stage of cancer:Grade of cancer: Treatment: Surgery Radiation Chemotherapy Other If other, please describe: If surgery, select type: Polyp(s) removed Resection Complete removal with colostomy Date of last treatment: Date Format: MM slash DD slash YYYY How often does the client have a cancer screen to detect possible recurrence? Date Format: MM slash DD slash YYYY Date of last colonoscopy: Date Format: MM slash DD slash YYYY Has there been any evidence of recurrence?YesNoIf yes, provide details: Any family history of colon cancer?YesNoIf yes, whom, onset age, age of death (if applicable):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