Angina QuestionnairePlease 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 AmountMax Premium $/yearTypeTermPermanentHas 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 Δ