Breast Cancer Questionnaire Step 1 of 4 25% Email* Who is filling out the form?*AgentClientAgentAgent Name* First Last Agent CompanyInsured Name* First Last Insured Email* Insured Phone*Address of InsuredAddress* Street Address Address Line 2 Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Sex*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Save and Continue Later Do you Currently Smoke?*YesNoDid you ever smoke?*NeverQuitWhen did you quit?* Date Format: MM slash DD slash YYYY Do you currently use any other tobacco products?* (e.g. nicotine patch, cigars, pipe, snuff, Nicorette gum...)YesNoPlease provide details*When did you last use any form of tobacco?Month*Please enter a number from 1 to 12.Year*Please enter a number from 1920 to 2030.Type Used?*HeightFt*In*WeightLbs* Save and Continue Later Date of Diagnosis* Date Format: MM slash DD slash YYYY Date of last treatment* Date Format: MM slash DD slash YYYY Exact name of the type of breast cancer that has been diagnosed*What was the Stage of the cancer?*Stage 0 - Ductile carcinoma in-situStage 0 - Lobular carcinoma in-situStage 0 - Paget’s disease of nippleStage IStage IIStage IIIAStage IIIBStage IVWas the cancer Graded?*YesNoWhat Grade was assigned?*Grade IGrade IIGrade IIIGrade IVHow has the cancer been treated?*(please check all that apply) Excisional biopsy (limited excision) Lumpectomy (wide excision) Partial Mastectomy Modified Radical Mastectomy Radical Mastectomy Radiation Therapy Chemotherapy Hormone Therapy Bone Marrow Transplant No treatment Save and Continue Later Do you take any medications at this time?*YesNoPlease Describe your medications.*Please include the name of the medication, date last used, quantity taken, and frequency taken.Has there ever been any evidence of recurrence?*YesNoDetails*Has there ever been any other kind of other cancer diagnosed?*YesNoDetails*Do you have any other medical conditions?*YesNoPlease Describe* Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.