Ovarian Cancer

Ovarian Cancer 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
Date of last treatment:
MM slash DD slash YYYY
Exact name of the ovarian cancer:
What was the stage of the cancer diagnosed (this information should be contained in the pathology report)?
- I
- II
- III
- IV
- Other staging method
If Other staging method used, please specify.
If the cancer was graded, what grade was assigned?
- I
- II
- III
- IV
- Other grading method
If Other grading method used, please specify.
How has the cancer been treated?
- Surgery
- Radiation
- Chemotherapy
- Biological therapy
- Hormone therapy
- Other
If Other please describe.
If surgery, what was removed?
Most current reading for the CA 125 marker:
Date of this reading:
MM slash DD slash YYYY
Describe any recurrence or other cancer that may have occurred:
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

Ovarian Cancer

Ovarian Cancer Questionnaire