Drug Use 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 MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)? Yes No Frequency Date of Last Use Type Does the client presently use any drugs other than those prescribed by a physician or those available over the counter? Yes No If no, date of last drug use: MM slash DD slash YYYY If yes, complete table below.Click the + sign to add more rows. TypeUsual QuantityFrequency of UseHow Taken; IVDates: From - To Did the client ever use other drugs or more drugs than they currently use? Yes No If yes, complete table below.Click the + sign to add more rows. TypeUsual QuantityFrequency of UseHow Taken; IVDates: From - To Is the client currently attending N.A. meetings or similar recovery groups? Yes No Has the client ever been treated for excessive drug use? Yes No If yes, provide date(s) and details: Any relapses? Yes No If yes, provide date(s) and details: Any legal troubles because of drug use? Yes No If yes, provide date(s) and details: Any driving violations? Yes No If yes, provide date(s) and details: MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken Is the client taking or has the client ever been prescribed Suboxone or any other medication to control his/her drug use? If yes, please provide 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 Δ