Parkinson’s Disease 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 Note the current functional stage of the client? Stage I - Unilateral involvement Stage II - Bilateral involvement but normal stance Stage III - Bilateral involvement with mild postural imbalance but able to lead an independent life Stage IV - Bilateral involvement with postural instability; requires substantial help Stage V - Severe disease; restricted to bed or wheelchair Has there been any evidence of progression? Yes No If yes, provide details: Have any of the following occurred? (select all that apply) Dementia Memory problems Depression Recurrent infections Falls Recurrent injuries Is the client independent (could live alone without assistance)? Yes No If no, list extent of disability below: Is the client receiving disability payments due to inability to work full-time? Yes No If yes, provide details below. 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