Cardiomyopathy

Cardiomyopathy 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
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.

Relation	Age (if living)	Age at Death	Cause of Death

Medications

Click the + sign to add additional medications.

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

List any other major health problems the client has:
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