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 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 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 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? 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 MedicationsClick 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? 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 Δ