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 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 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? Yes No Date: MM slash DD slash YYYY Results: Normal Abnormal CT scan? Yes No Date: MM slash DD slash YYYY Results: Normal Abnormal MRI? Yes No Date: MM slash DD slash YYYY Results: Normal Abnormal Biopsy? Yes No Date: 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: 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