Sleep Apnea 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 Date of diagnosis: MM slash DD slash YYYY Diagnosed as: Obstructive Central Mixed Unknown Severity: Severe Moderate Mild Has an overight sleep study been done? Yes No If Yes, provide sleep index AHI and RDI: Lowest oxygen saturation (%): How is the sleep apnea being treated? No treatment Medicated Weight loss CPAP Mask Surgery (UPPP) Surgery (tracheotomy) Other If Other, please specify. Does the client have any of the following: Overweight Arrhythmia Coronary Artery Disease Stroke Depression Lung Disease If yes to any above, please provide details: Does the client use alcohol? Yes No If yes, describe usage: 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