Atrial and Venticular Septal Defects 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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseTypeDate of Diagnosis:Check type of septal defect: ASD, ostium secundum or sinus venosus ASD, primum VSD, large VSD, small VSD, moderate Has surgical repair(s) been completed? If yes, provide details below:Are any other congenital defects present? Provide details. Check if any of the following have occurred before or after surgery and provide details.Heart enlargement?Pulmonary hypertension?Bundle branch block on ECG?Arrhythmia?Symptoms?Blood clots?Stroke?Heart valve disease?Is the client on any medications? If yes, provide details.Date of recent echocardiogram: Date Format: MM slash DD slash YYYY Results:List any other major health problems the client has: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