Life Insurance For Survivors

BREAST CANCER SURVIVOR QUESTIONNAIRE:

Name:	Date of Birth:
Email:	Phone:
Height: Weight:	Sex: State of Residence:
1. What was the date of your diagnosis?
2. How was the cancer treated?
3. Please list date treated completed:
4. Are you taking any medications?	Yes No
5. What stage was the cancer?
6. Were lymph nodes involved?	Yes No If yes, how many?
7. Has there been any evidence of recurrence?	Yes No
If you selected "Yes" in question #7, please explain:
8. Date and results of last mammogram:
9. When was your last colonoscopy and CEA level? Please give date and results:
10. Have you smoked cigarettes in the last 12 months?	Yes No
11. Do you have any other major health problems (ex: cancer, etc.)?	Yes No
12. Amount of Life Insurance you are considering?
Type of coverage?
13. Is your pathology report available?	Yes No
If you selected "Yes" in question #13, please submit along with questionnaire:	Upload your file below:
Tumor size:
Call me today Toll Free 1-877-875-2555, Press 0 - 9 am to 5 pm EST Steve Bazzano L. Bissell & Son, Inc Po Box 178 Rockville, Ct. 06066 www.lifeinsuranceforsurvivors.com Fax: 860-875-1262