Testicular Cancer

Testicular Cancer 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
Date of last treatment:
Date Format: 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:
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