Prostate 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 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 Date of last treatment: What stage was the cancer diagnosed (information should be contained in the pathology report)? T1a T1b T1c T2a T2b T2c T3a T3b T4 Any lymph nodes positive for cancer? Yes No If yes, how many? Any metastasis (spread of cancer) to other areas of the body? Yes No Gleason Score: Date/Results of last PSA test prior to treatment: Date/Results of most recent PSA test: Has the cancer been treated? Observation only Radiation therapy (seeds) Radical prostatectomy Hormone therapy Transurethral prostatectomy (TURP) Biological therapy Any evidence of recurrence? 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