Uterine/Cervical Cancer

Uterine/Cervical 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
MM slash DD slash YYYY
Client Name
Date of Birth
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
Type of cancer:
- Endometrial - Adenoscarcinoma
- Endometrial - Leiomyosarcoma
- Cervical
Date of diagnosis:
MM slash DD slash YYYY
Stage of cancer - Endometrial:
- 0
- 1
- 1a
- 1b
- 1c
- 2
- 3
- 4
Stage of cancer - Cervical:
- 0
- 1
- 1a
- 1b
- 2
- 2a
- 2b
- 3
- 4
Treatment:
- Total hysterectomy
- Radiation therapy
- Chemotherapy
- Hormonal therapy
- Cryosurgery/Laser
- Cone biopsy
- LEEP
Date treatment completed:
MM slash DD slash YYYY
Any evidence of recurrence?
- Yes
- No
Current frequency of checkups:
Date of most recent Pap smear:
Results?
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