Hepatitis

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
MM slash DD slash YYYY
Client Name
Date of Birth
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:
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

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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