Pancreatitis

Pancreatitis 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 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).
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