Rheumatoid Arthritis

Rheumatoid Arthritis 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
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:
MM slash DD slash YYYY
Treatment:
Is the client on disability:
- Yes
- No
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