Pancreatitis 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 diagnosis: MM slash DD slash YYYY Cause: Have any of the following symptoms occurred? Cyst, Pseudocyst Abscess Stone Other If Other, please specify. Was the client incapacitated from work due to the pancreatic disorder? Yes No If yes, when and for how long? Was the client hospitalized? Yes No If yes, provide date(s). Was any surgery performed? Yes No If yes, provide detail(s). Describe frequency of attacks. Any alcohol consumption? Yes No If yes, provide detail(s). 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