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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
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
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

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Moseley McGill, LLC is a Marketing Firm assisting Insurance Professionals in Estate Creation, Protection and Preservation, Quoting Services, Advanced Case Design and Case Management.

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