Uterine/Cervical 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 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? 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