Melanoma/Skin Cancer 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType What type of skin cancer was diagnosed? Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Dysplastic nevi syndrome Date of diagnosis: Date Format: MM slash DD slash YYYY Date of last treatment: Date Format: MM slash DD slash YYYY Number of lesions: Location of skin cancer(s): How has the cancer been treated? Surgery Other If surgery, provide date(s):If Other, please describe: Clark Level of the cancer (malignant melanoma only): I(1) II(2) III(3) IV(4) V(5) Breslow Scale of the cancer (malignant melanoma only): In-situ 0.74 mm or less 0.75 mm to 1.50 mm 1.51 mm to 4.00 mm 4.01 mm plus TNM Stage T1a T1b T2a T2b T3a T3b T4a T4b Any N1-3 M1 Any evidence of recurrence?YesNoIf yes, provide details: Any family history of melanoma?YesNoIf yes, provide details: Any family history of dysplastic nevi syndrome?YesNoIf 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