Hemochromatosis 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 What organs are involved (select all that apply): Liver Pancreas (Diabetes) Joints Heart Pituitary Date of last phlebotomy treatment: MM slash DD slash YYYY Was a liver biopsy or ultrasound done? (If yes, provide a copy to jrmosel@moseleymcgill.com) Yes No If available, provide the most recent results for:Serum ferritinIron levelASTALT 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 Δ