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 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 diagnosis: Date Format: 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?YesNoIf yes, when and for how long? Was the client hospitalized?YesNoIf yes, provide date(s). Was any surgery performed?YesNoIf yes, provide detail(s). Describe frequency of attacks. Any alcohol consumption?YesNoIf 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