Atrial Fibrillation 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 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: 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: MM slash DD slash YYYY Does the client have high cholesterol, total cholesterol? HDL LDL Ratio Date: 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 Δ