Cardiac Disease

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Cardiac Disease 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
MM slash DD slash YYYY
Client Name
Date of Birth
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
Has the client had a heart attack?
- Yes
- No
If yes, provide date:
MM slash DD slash YYYY
Provide dates if any of the following tests have been completed:
Resting EKG (Date):
MM slash DD slash YYYY
Stress thallium (Date):
MM slash DD slash YYYY
Stress echo (Date):
MM slash DD slash YYYY
Stress test (Date):
MM slash DD slash YYYY
Echocardiogram (Date):
MM slash DD slash YYYY
EBCT (CT of the heart) (Date):
MM slash DD slash YYYY
Other (Date):
Provide dates and results of any surgical procedures
Bypass (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?
- Yes
- No
If yes, age of onset:
Recent A1c result:
Has the client been diagnosed with high blood pressure?
- Yes
- No
Most recent reading:
Has the client been diagnosed with irregular heartbeat?
- Yes
- No
Other arterial disease?
- Carotid
- Peripheral Vascular
- Cerebrovascular
Does the client take any current medications, including preventative aspirin?
- Yes
- No

Medications

Click on the + sign to add additional medications.

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Does the client engage in any regular exercise or sporting activity?
- Yes
- No
If 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

Cardiac Disease

Cardiac Disease Questionnaire