Multiple Sclerosis

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Multiple Sclerosis 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
Date of first diagnosis:
Date Format: 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
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:
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

Approximate Date of Attack(s)	Duration of Attack(s)	Residual Effects (Choose One: None, Minimal, Moderate, Severe)	Specify impairment for Residual Effects

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Multiple Sclerosis

Multiple Sclerosis Questionnaire