Thyroid 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 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 Type of thyroid cancer: Papillary Mixed Papillary Follicular Anaplastic Hurthle Cell Primary thyroid lymphoma Tumor confined:YesNo Lymph node involvement/metastasis:YesNo Tumor size: Less than 4 centimeters 4 centimeters or more (extracapsular extension) Stage of cancer: Cancer treatment: Surgery Radiation Chemotherapy Treatment start date:Treatment end date: Any evidence of recurrence?YesNoIf 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