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Cardiac Disease

  • Cardiac Disease Questionnaire

    Please answer all questions applicable to the client's medical history.
    Questions? Call Jim or Teresa at 877.564.1707.

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  • Date Format: MM slash DD slash YYYY

  • Provide dates if any of the following tests have been completed:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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  • Provide dates and results of any surgical procedures








  • Click on the + sign to add additional medications.
    Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken 


  • 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

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