Ovarian 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 Date of first diagnosis: Date Format: MM slash DD slash YYYY Date of last treatment: Date Format: 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: Date Format: MM slash DD slash YYYY Describe any recurrence or other cancer that may have occurred: 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