Prostate Cancer

Prostate Cancer 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
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.
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

Prostate Cancer

Prostate Cancer Questionnaire