Hepatitis 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 diagnosis: Date Format: MM slash DD slash YYYY How was the client infected? Current symptoms: The hepatitis has been diagnosed as: Acute Viral Hepatitis A Resolved Acute Viral Hepatitis B Resolved Chronic Active Hepatitis B Unresolved Chronic Persistent Hepatitis C Hepatitis A Unresolved Chronic Persistent Hepatitis B Unresolved (e.g. carrier) Acute Viral Hepatitis C Chronic Active Hepatitis C Other If Other, please describe: Most current liver enzyme levelsDateGGTPALT/SGPTAST/SGOTHBV RIBAAnti HCVHCV Viral LoadHB Viral Load Which studies have been done to diagnose/treat the conditionLiver ultrasound?YesNoDate: Date Format: MM slash DD slash YYYY Results:NormalAbnormal CT scan?YesNoDate: Date Format: MM slash DD slash YYYY Results:NormalAbnormal MRI?YesNoDate: Date Format: MM slash DD slash YYYY Results:NormalAbnormal Biopsy?YesNoDate: Date Format: MM slash DD slash YYYY Results:NormalAbnormal Studies recommended/pending:Date planned: Has the client been treated for hepatitis?YesNo If treated, begin date:If treated, end date: 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