Diabetes Mellitus

Diabetes Mellitus 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
Type of Diabetes:
- Type I
- Type II
Date of diagnosis:
MM slash DD slash YYYY
Age at onset:
Most current Glycohemoglobin (HbA1C) test reading:
Date:
MM slash DD slash YYYY
Recent range:
How often does the proposed insured visit their physician for a diabetic checkup?
Date of most recent physician visit:
MM slash DD slash YYYY
The client controls his/her diabetes by:
- Diet only
- Weight loss/control
- Regular exercise (indicate type and frequency below)
- Oral medication
- Insulin
Exercise type and frequency:
If taking insulin, how many units per day?

Medications

Click the + sign to add additional medications.

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Current Height:
Current Weight:
Weight 1 year ago:
Reason for change:
Blood sugar reading:
A1C level:
Microalbumin Level;
Triglycerides:
Bad cholesterol (LDL):
Good cholesterol (HDL):
Cholesterol (HDL):
Blood Pressure
Has the proposed insured experienced any of the following - if yes, provide details below:
- Weight problems
- High blood pressure
- Chest pain
- Insulin shock
- Coronary Artery Disease
- Abnormal ECG
- Elevated lipids
- Diabetic coma
- Neuropathy
- Retinopathy
- Kidney disease
- Alcohol/drug abuse
- Protein in the Urine
- Albuminuria
- Glycosuria
- Other
Details:
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