Rheumatoid Arthritis 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Date of diagnosis: Date Format: MM slash DD slash YYYY Select if the client has had any of the following: Weight loss Fever Low blood counts Heart disease Lung disease Liver enzyme abnormality Kidney disease What joints are involved? Select functional ability: Fully active Sedentary Uses walker, cane, etc. Uses wheelchair Date of last flare up: Date Format: MM slash DD slash YYYY Treatment: Is the client on disability:YesNo 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