CERVICAL CANCER QUESTIONNAIRE - FAIU 2026

1. Click ‘Get Form’ to open the CERVICAL CANCER QUESTIONNAIRE in the editor.
2. Begin by entering your name (Last, First, M.I.) and date of birth (DOB) in the designated fields.
3. Fill in your height and weight as requested. This information is essential for your health history.
4. In the HEALTH HISTORY section, provide the date of diagnosis and check all applicable treatment options such as cone surgery, total hysterectomy, chemotherapy, or radiation therapy.
5. Indicate when treatment was completed and specify the stage of cancer from the provided options.
6. Answer whether there has been any evidence of recurrence and provide details if applicable.
7. List any medications your client is currently taking and confirm if they have smoked cigarettes in the last 12 months.
8. Finally, indicate if there are any other major health problems and include a pathology report of cervical cancer if available.
9. Sign the form to confirm that all statements are true and complete. Include the date along with agent's name and broker manager's name where required.

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