Home
Forms Library
Peptic ulcer questionnaire

Peptic ulcer questionnaire 2025

peptic ulcer questionnaire Preview on Page 1

See details

4 out of 5

23 votes

The document is a Peptic Ulcer Questionnaire used for insurance purposes, requiring information about the client's medical history related to peptic ulcers, including diagnosis dates, treatment methods, recurrence of ulcers, medication use, smoking status, and other major health issues. It includes sections for agent and insured signatures and instructions to fax the completed form.

Here's how it works

01. Edit your peptic ulcer questionnaire online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send questionnaire for peptic ulcer patient via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out peptic ulcer questionnaire with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the peptic ulcer questionnaire in the editor.
Begin by entering the policy number and date at the top of the form. This information is crucial for identifying your document.
Fill in the broker's details, including name, phone number, and fax number. This ensures proper communication regarding the questionnaire.
Provide client information such as name, age/DOB, and sex. This section helps in personalizing the assessment.
Select the appropriate policy type by checking one of the options: Term, UL, Whole Life, LTC, or DI.
If applicable, detail your client's history of peptic ulcer disease by listing the date of first diagnosis and treatment methods used (medications or surgery).
Indicate if there have been any recurrences or additional episodes and provide details if necessary.
Complete any additional health questions regarding medications and smoking history to give a comprehensive view of your client's health status.
Finally, ensure both agent and insured signatures are provided along with dates before submitting via fax to Rohrer & Associates.

Start filling out your peptic ulcer questionnaire online for free today!

See more peptic ulcer questionnaire versions

We've got more versions of the peptic ulcer questionnaire form. Select the right peptic ulcer questionnaire version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2003	4 Satisfied (23 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the gold standard test for peptic ulcers?

Esophagogastroduodenoscopy (EGD): Gold standard and most accurate diagnostic test with sensitivity and specificity up to 90% in diagnosing gastric and duodenal ulcers.

What is the assessment of peptic ulcers?

Doctors may order an upper GI endoscopy to confirm the diagnosis of a peptic ulcer and try to find its cause. For an upper GI endoscopy, a doctor uses an endoscopea flexible tube with a camerato see the lining of your upper GI tract, including your esophagus, stomach, and duodenum.

What are the clinical findings of peptic ulcer disease?

Patient reporting of epigastric abdominal pain, early satiety, and fullness following a meal raise suspicion of PUD. The pain of gastric ulcers increases 2 to 3 hours after a meal and may result in weight loss, whereas the pain of duodenal ulcers decreases with a meal which can result in weight gain.

What tests to order for peptic ulcer?

Laboratory Testing Endoscopy with biopsy to obtain a tissue sample to test for the bacteria. Urea breath tests, a noninvasive method. Serologic testing, a blood test. Stool antigen, another noninvasive method of testing for H. pylori.

What are the examination findings of peptic ulcers?

In uncomplicated peptic ulcer disease, the clinical findings are few and nonspecific and include the following: Epigastric tenderness (usually mild) Right upper quadrant tenderness may suggest a biliary etiology or, less frequently, peptic ulcer disease. Guaiac-positive stool resulting from occult blood loss.

What are the findings of a peptic ulcer exam?

Most patients describe generalized pain; a few present with severe epigastric pain. As even slight movement can tremendously worsen their pain, these patients assume a fetal position. Abdominal examination usually discloses generalized tenderness, rebound tenderness, guarding, and rigidity.

What is the most common presentation of a peptic ulcer?

What are peptic ulcer symptoms? Up to 70% of people with peptic ulcer disease dont notice any symptoms. But the most common symptoms people report are epigastric pain (central upper abdominal pain) and indigestion (dyspepsia). These symptoms come and go persistently.

Peptic ulcer questionnaire 2025

Here's how it works

How to use or fill out peptic ulcer questionnaire with our platform