Prostate Specific Antigen (PSA) Elevation 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 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 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