Thyroid Cancer

Thyroid 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
Type of thyroid cancer:
- Papillary
- Mixed Papillary
- Follicular
- Anaplastic
- Hurthle Cell
- Primary thyroid lymphoma
Tumor confined:
- Yes
- No
Lymph node involvement/metastasis:
- Yes
- No
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?
- 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