Atrial and Venticular Septal Defects

Atrial and Venticular Septal Defects 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
Date 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:
MM slash DD slash YYYY
Results:
List any other major health problems the client has:
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