Prostate Specific Antigen (PSA) Elevation

Prostate Specific Antigen (PSA) Elevation 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
What condition has been diagnosed?
Date of diagnosis:
MM slash DD slash YYYY
Date of most recent PSA test:
MM slash DD slash YYYY
Result:
Date of highest PSA level ever recorded:
MM slash DD slash YYYY
Result:
Was a free PSA test completed?
- Yes
- No
Date
MM slash DD slash YYYY
Result
Has there been any treatment?
- Yes
- No
Date
MM slash DD slash YYYY
Provide treatment description below.
Date of most recent digital rectal exam of the prostate:
MM slash DD slash YYYY
Result:
Date of most recent ultrasound of the prostate:
MM slash DD slash YYYY
Result:
Date of most recent prostate biopsy:
MM slash DD slash YYYY
Results:
- BPH
- High grade PIN
- Low grade PIN
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:
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

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Prostate Specific Antigen (PSA) Elevation

Prostate Specific Antigen (PSA) Elevation Questionnaire