Gastric Bypass 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 of procedure: Date Format: MM slash DD slash YYYY Type of procedure (e.g. gastric bypass, banding, etc.): Weight prior to procedure:Current weight: Has weight loss been stable/maintained?YesNo Height:Please provide details if any of the following complications have occurred: Hemorrhage? If yes, provide details:Obstruction? If yes, provide details:Perforation? If yes, provide details:Leaks? If yes, provide details:Abnormal liver function studies? If yes, provide details:Hypoglycemia? If yes, provide details:Anemia? If yes, provide details:Nutritional deficiencies? If yes, provide details:Vomiting or nausea? If yes, provide details:Change in bowel habits/diarrhea due to dietary modifications? If yes, provide details:Failure to lose weight? If yes, provide details:Problems retaining weight? If yes, provide details:Dumping syndrome? If yes, provide details:Any history, past or present, of associated chronic disease including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, or cardiovascular disease?YesNoIf yes, provide details below:MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken 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