Colorectal Cancer

Colorectal Cancer 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
Date of first diagnosis:
MM slash DD slash YYYY
Date of last diagnosis:
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:
MM slash DD slash YYYY
How often does the client have a cancer screen to detect possible recurrence?
MM slash DD slash YYYY
Date of last colonoscopy:
MM slash DD slash YYYY
Has there been any evidence of recurrence?
- Yes
- No
If yes, provide details:
Any family history of colon cancer?
- Yes
- No
If yes, whom, onset age, age of death (if applicable):
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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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Colorectal Cancer

Colorectal Cancer Questionnaire