Hepatitis

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Hepatitis 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
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 levels
Date GGTP ALT/SGPT AST/SGOT HBV RIBA Anti HCV HCV Viral Load HB Viral Load
Which studies have been done to diagnose/treat the condition
Liver ultrasound?
- Yes
- No
Date:
Date Format: MM slash DD slash YYYY
Results:
- Normal
- Abnormal
CT scan?
- Yes
- No
Date:
Date Format: MM slash DD slash YYYY
Results:
- Normal
- Abnormal
MRI?
- Yes
- No
Date:
Date Format: MM slash DD slash YYYY
Results:
- Normal
- Abnormal
Biopsy?
- Yes
- No
Date:
Date Format: MM slash DD slash YYYY
Results:
- Normal
- Abnormal
Studies recommended/pending:
Date planned:
Has the client been treated for hepatitis?
- Yes
- No
If treated, begin date:
If treated, end date:
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:
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

Date	GGTP	ALT/SGPT	AST/SGOT	HBV RIBA	Anti HCV	HCV Viral Load	HB Viral Load

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Hepatitis

Hepatitis Questionnaire