Depression 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(s) of initial and subsequent episodes of depression: What specific type(s) of depression has been diagnosed? Bipolar disorder (mixed) Bipolar disorder (manic) Bipolar disorder (depressed) Dysthymia Major depression Anxiety Situational depression Other If other, please describe: What medications are used to treat the condition?Click the + sign to add additional medications. TypeUsual QuantityFrequency of UseHow TakenDates: From-To Has the client ever been hospitalized or gone to the Emergency Room for any depression/anxiety symptoms?YesNoIf yes, list date(s): Has the client been treated with electric shock therapy (ECT)?YesNoIf yes, total number of ECT treatments:Date of first ECT treatment: Date Format: MM slash DD slash YYYY Date of most recent ECT treatment: Date Format: MM slash DD slash YYYY Has the client had (or been diagnosed with) Alcohol/Drug abuse?YesNoDate of last use: Date Format: MM slash DD slash YYYY Has the client had (or been diagnosed with) Anorexia/Bulimia nervosa?YesNoDate diagnosed: Date Format: MM slash DD slash YYYY Has the client had (or been diagnosed with) Personality/Psychotic disorder?YesNoDate diagnosed and exact name of condition: Date Format: MM slash DD slash YYYY Has the client had (or been diagnosed with) suicidal thoughts/attempts?YesNoDate of last such thought/attempt: Date Format: MM slash DD slash YYYY The client is: Working On disability 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