Monoclonal Gammopathy

Monoclonal Gammopathy 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 first diagnosis:
MM slash DD slash YYYY
Was a bone marrow biopsy done?
- Yes
- No
If yes, provide details:
Provide the most recent reading for Serum Protein/Serum Electrophoresis:
Provide the most recent reading for BUN:
Provide the most recent reading for Creatinine:
Provide the most recent reading for Urinalysis:
Provide the most recent reading for M Protein:
Have the elevated protein (Ig) levels remained stable since diagnosis?
- 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