Get Peptic Ulcer Questionnaire

The Peptic Ulcer Questionnaire is a vital document used to assess a client's medical history related to peptic ulcers. This guide will provide you with clear and supportive instructions on how to effectively fill out the form online, ensuring accurate and comprehensive information is provided.

Follow the steps to complete the Peptic Ulcer Questionnaire online

1. Press the ‘Get Form’ button to access the Peptic Ulcer Questionnaire and open it in your preferred editor.
2. Fill in the policy number in the designated space at the top of the form.
3. Enter the date in the appropriate format (MM/DD/YYYY).
4. In the section labeled ‘Broker’, provide the broker's name, followed by their phone and fax numbers.
5. For the ‘Client’ section, input the client's name, age or date of birth, and sex.
6. Select the policy type by checking the appropriate box next to one of the options: Term, UL (Universal Life), Whole Life, LTC (Long-Term Care), or DI (Disability Insurance).
7. If the client has a history of peptic ulcer disease, enter the date of the first diagnosis in the specified area.
8. Detail the treatment of the ulcer. If medications were used, provide the names and details in the provided space.
9. If surgery was performed, enter the date and type of surgery.
10. Indicate whether repeat surgery was required by answering 'yes' or 'no' and providing additional details if applicable.
11. Address if the client has experienced any recurrences or multiple episodes by answering 'yes' or 'no', giving specifics if necessary.
12. State if the client is on any other medications. If 'yes', list the medications in detail.
13. Answer whether the client has smoked cigarettes in the last 12 months by selecting 'yes' or 'no'.
14. Indicate if the client has any other major health problems, providing details if the answer is 'yes'.
15. Have the agent and insured person sign the form, along with entering the date of the signatures.
16. Once completed, save changes to the form, then proceed to download, print, or share it as needed.

Complete the Peptic Ulcer Questionnaire online today for a streamlined process.