Fibromyalgia/Chronic Fatigue 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 Date of diagnosis: MM slash DD slash YYYY Name of diagnosis: Symptoms at time of diagnosis - provide details: Current symptoms - provide details: Has there been a complete recovery? Yes No Residual symptoms - provide details: Is there any interference with normal activities of daily living (ADLs)? If yes, provide details: Any hospitalization(s)? Yes No If yes, provide date and reason: Any psychiatric consultations? Yes No If yes, provide date(s): MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken The client is: Working full-time Working part-time On disability Other Client hobbies/activities: 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