Cancer Questionnaire

        

                                                                          

                                                                                             

                                                                                             

                                                                                             

 

What type of cancer was diagnosed?                               

Approximate date of diagnosis?                                         

                                                                                             

              
                                                                                    

                                                                                    

                                                                                             

                                                                                       

                                                                                            

Full name:                                                                                     

*Phone no:                                                                            

*Email address:                                                                     

Best time to be contacted:                                                                 

 

 

       

 

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Special Risk Managers Pty Ltd is a member firm and corporate authorised representative of Count Financial Limited ABN 19 001 974 625 AFSL 227232

 
*Date of Birth:
Height:
Weight:
Type of insurance you want:

What treatment did/do you receive? 

If you had Prostate Cancer, what was the Gleason’s Grade?
What was the stage of the tumor/malignancy?
What part of the body is/was affected?
If you had Colon or Rectal cancer, what was the Duke’s Scale?
If you had a Melanoma, what was the Clark’s Level?
How long have you been in remission?
Have you smoked in the last 12 months?