Hodgkin’s/Non-Hodgkin’s Disease 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 Type of Hodgkin's lymphoma: Lymphocyte predominance Mixed cellularity Nodular sclerosis Lymphocyte depletion Other If Other, please specify: Date of initial diagnosis: MM slash DD slash YYYY Date of last treatment: MM slash DD slash YYYY How has the disease been treated (select all that apply): Chemotherapy Chemotherapy with alkylating agents Radiation therapy Bone marrow transplant Stem cell treatment Other If Other, please describe: Hodgkin's Stage I II III IV Hodgkin's Subcategory: A B E Non-Hodgkin's Stage I II III IV Non-Hodgkin's Grade Low Intermediate High Non-Hodgkin's Suffix B E Any evidence of recurrence? Yes No If yes, provide details: 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