Diabetes Mellitus 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 Type of Diabetes: Type I Type II Date of diagnosis: Date Format: MM slash DD slash YYYY Age at onset: Most current Glycohemoglobin (HbA1C) test reading:Date: Date Format: 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: Date Format: 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? MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency 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 PressureHas 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