Blood Clots

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Blood Clots 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
Cause of blood clot:
- Atrial Fibrillation
- PFO (Patent Foramen Ovale)
- Travel
- ASD (Atrial Septal Defect)
- Sedentary Lifestyle
- Post-Operative Complication
- Other
If Other, please describe:
Clotting Disorder:
- Factor V Leiden Resistance
- Lupus Anticoagulant
- Antiphospholipid Antibody
- Other
If Other, please describe:
Date of first diagnosis:
Date Format: MM slash DD slash YYYY
Type of treatment: Blood thinner (coumadin)? If yes, please provide date(s).
Type of treatment: Aspirin? If yes, please provide date(s).
Type of treatment: Hospitalization? If yes, please provide date(s).
Any evidence of recurrence?
- Yes
- No
If yes, provide dates/details:
Have any of the following occurred due to blood clots?
- Heart attack
- Stroke
- Deep vein thrombosis (DVT)
- Pulmonary embolism
- Other
If Other, please describe:
Medications
Click on the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Blood Clots

Blood Clots Questionnaire