Hemochromatosis

Hemochromatosis Questionnaire
Please 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 Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of diagnosis:
Date Format: MM slash DD slash YYYY
What organs are involved (select all that apply):
- Liver
- Pancreas (Diabetes)
- Joints
- Heart
- Pituitary
Date of last phlebotomy treatment:
Date Format: 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 ferritin Iron level AST ALT
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken