Moseleymcgill – Angina

Angina Questionnaire

Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.

Producer Name*

Phone*

Email*

Date

Client Name

Date of Birth

Gender

Male
Female

Face Amount

Max Premium $/year

Type

Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?

Yes
No

Frequency

Date of Last Use

Type

If the client has had chest pain or angina, please answer the following. Date of first occurrence:

Is the client on any medications (including aspirin):

Yes
No

If yes, please provide details:

Has the client had any of the following tests (check all that apply):

Angiography
MUGA Scan
Resting EKG
Stress Echocardiogram
Stress EKG
Thallium Stress EKG
Ultrafast CT

Check if the client has had any of the following:

Abnormal Lipid Levels
Diabetes
Elevated Homocysteine
Family History of Heart Disease
High Blood Pressure

Provide the dates and details for the following (if applicable):

Heart Attack(s):

Bypass Surgery(s):

Bypass Surgery(s) Number of Vessels:

Angioplasty(s):

Angioplasty(s) Number of Vessels:

List any other major health problems the client has:

Please submit the actual tracings and results of all stress electrocardiograms and any further testing if done (thallium, echo, or angiogram). Email to: jrmosel@moseleymcgill.com.

For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections