Multiple Sclerosis 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 Date of first diagnosis: MM slash DD slash YYYY Type of multiple sclerosis: Relapsing-remitting Progressive Benign (no signs or symptoms for 5+ years) How was the condition diagnosed? MRI Evoked Potentials Other If Other, please specify. Describe Attack(s)Please click the + sign to describe additional attacks. Approximate Date of Attack(s)Duration of Attack(s)Residual Effects (Choose One: None, Minimal, Moderate, Severe)Specify impairment for Residual Effects If there is a disability, provide the score for the Expanded Disability Status Scale (EDSS) or describe the disability. EDSS Score (0 thru 10): Or describe the disability: Work status: Currently working On disability Third Choice 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