Testicular Cancer 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 Date of last treatment: MM slash DD slash YYYY Type of cancer: Seminoma Non-Seminoma Non Germ Cell Sarcoma Stage: I II III IV A B C How was the cancer treated (select all that apply)? Surgery Radiation Chemotherapy Other If other, please specify: How often does the client have a cancer screen to detect possible recurrence? Any evidence of recurrence? Yes No If yes, provide details below: 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