Cardiomyopathy 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 Date of diagosis: MM slash DD slash YYYY This condition has been diagnosed as: Dilated cardiomyopathy Myocarditis Mycardial fibrosis Mycardial degeneration Congestive cardiomyopathy Hypertrophic cardiomyopathy Idiopathic hypertrophic subaortic stenosis Alcoholic cardiomyopathy Peripartum cardiomyopathy Restrictive cardiomyopathy Other If Other, please provide details: MM slash DD slash YYYY Provide dates if any of the following tests or procedures have been done to evaluate the condition:Resting EKG (Date): MM slash DD slash YYYY Thallium stress EKG (Date): MM slash DD slash YYYY Holter monitor (Date): MM slash DD slash YYYY Stress EKG (Date): MM slash DD slash YYYY Echocardiogram (Date): MM slash DD slash YYYY Chest X-ray (Date): MM slash DD slash YYYY Other (Date): Family history of heart disease or premature death due to heart disease:Click the + sign to add additional relatives.RelationAge (if living)Age at DeathCause of Death MedicationsClick the + sign to add additional medications. Name of Medication (prescription or otherwise)Dates UsedQuantity TakenFrequency Taken List any other major health problems the client has: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