Cardiac Disease 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 UseTypeHas the client had a heart attack?YesNoIf yes, provide date: Date Format: MM slash DD slash YYYY Provide dates if any of the following tests have been completed:Resting EKG (Date): Date Format: MM slash DD slash YYYY Stress thallium (Date): Date Format: MM slash DD slash YYYY Stress echo (Date): Date Format: MM slash DD slash YYYY Stress test (Date): Date Format: MM slash DD slash YYYY Echocardiogram (Date): Date Format: MM slash DD slash YYYY EBCT (CT of the heart) (Date): Date Format: MM slash DD slash YYYY Other (Date): Provide dates and results of any surgical proceduresBypass (CABG) Date and Results:Angioplasty (PTCA) Date and Results:Coronary artery stents Date and Results:How many vessels are involved? 1 2 3 or more Which vessels?Has the client been diagnosed with Diabetes?YesNoIf yes, age of onset:Recent A1c result:Has the client been diagnosed with high blood pressure?YesNoMost recent reading:Has the client been diagnosed with irregular heartbeat?YesNoOther arterial disease? Carotid Peripheral Vascular Cerebrovascular Does the client take any current medications, including preventative aspirin?YesNoMedicationsClick on the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken Does the client engage in any regular exercise or sporting activity?YesNoIf yes, provide details: List any other major health problems the client has:If at all possible, please obtain the pathology report. It will enable us to work with you prior to a formal application to determine if coverage is now available, at which insurance company, and for what likely premium.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