Sarcoidosis 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 How diagnosed (e.g. x-ray): What joints are involved? Was the condition staged?YesNo 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?YesNo If yes, select all affected: Lung Lymph nodes Kidney Eyes Heart Liver Central nervous system Other Any recurrence?YesNoIf yes, provide date(s): Select degree of obstruction on most recent pulmonary function testing: Normal Mild Moderate Severe 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