Atrial Fibrillation

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Atrial Fibrillation 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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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
Age/date when first diagnosed:
Type:
- Chronic (permanent)
- Paroxysmal (intermittent)
Current medications:
What is the cause of the atrial fibrillation?
Average number of episodes per year:
Date of last episode:
Date Format: MM slash DD slash YYYY
Has the client ever had an ablation procedure? If yes, please advise date:
Has the client ever had a cardioversion? If yes, please advise date:
Does the client have a pacemaker or defibrillator implanted?
- Yes
- No
If yes, what type?
Date of implant:
Does the client have high blood pressure?
- Yes
- No
High blood pressure reading(s):
Date:
Date Format: MM slash DD slash YYYY
Does the client have high cholesterol, total cholesterol?
- HDL
- LDL
- Ratio
Date:
Date Format: MM slash DD slash YYYY
Have any of the following tests been done?
- EKG
- Stress test
- Echocardiogram
- Holter monitor
- Other
If yes to any of the above tests, please provide Date and Results for each:
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

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Atrial Fibrillation

Atrial Fibrillation Questionnaire