Hodgkin’s/Non-Hodgkin’s Disease

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Hodgkin’s/Non-Hodgkin’s Disease 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
Type of Hodgkin's lymphoma:
- Lymphocyte predominance
- Mixed cellularity
- Nodular sclerosis
- Lymphocyte depletion
- Other
If Other, please specify:
Date of initial diagnosis:
Date Format: MM slash DD slash YYYY
Date of last treatment:
Date Format: 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:
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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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Hodgkin’s/Non-Hodgkin’s Disease

Hodgkin’s/Non-Hodgkin’s Disease Questionnaire