Sarcoidosis

Sarcoidosis 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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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:
Date Format: MM slash DD slash YYYY
How diagnosed (e.g. x-ray):
What joints are involved?
Was the condition staged?
- Yes
- No
If yes, select appropriate stage:
- Stage I
- Stage II
- Stage III
Describe current symptoms:
Treatment:
Date:
Date Format: MM slash DD slash YYYY
Has there been any organ involvement?
- Yes
- No
If yes, select all affected:
- Lung
- Lymph nodes
- Kidney
- Eyes
- Heart
- Liver
- Central nervous system
- Other
Any recurrence?
- Yes
- No
If yes, provide date(s):
Select degree of obstruction on most recent pulmonary function testing:
- Normal
- Mild
- Moderate
- Severe
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