Carotid Artery Stenosis

Carotid Artery Stenosis 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
Does the client have a history of Carotid Bruit (noise heard on examination due to turbulent blood flow in the carotid artery)?
- Yes
- No
Is the client diagnosed with single or bilateral carotid stenosis?
If known, percentage on right side?
Percentage on left side?
Provide date of last Carotid ultrasound:
MM slash DD slash YYYY
Has the client had an Endarterectomy (removal of carotid plaque) or stenting for carotid stenosis?
- Yes
- No
If yes, which method of treatment did he/she have?
Date of procedure:
MM slash DD slash YYYY
Does the client take Anticoagulants/blood thinning medication (e.g. Aspirin, Coumadin)?
- Yes
- No
Does the client have a history of high blood pressure?
- Yes
- No
If yes, provide a recent reading (if known):
MM slash DD slash YYYY
Does the client have a history of high cholesterol?
- Yes
- No
Total Cholesterol:
HDL:
Triglycerides:
Does the client have a history of Diabetes?
- Yes
- No
If yes, what type:
- Type 1
- Type II
Date diagnosed:
MM slash DD slash YYYY
Recent A2C level:
Does the client have a history of TIA (transient ischemic attack)?
- Yes
- No
If yes, provide date:
MM slash DD slash YYYY
Does the client have a history of Stroke?
- Yes
- No
If yes, provide date:
MM slash DD slash YYYY
Provide details of any residual impairment caused by the stroke (e.g. paralysis, weakness, other):
Does the client have a history of Blood Clot?
- Yes
- No
If yes, provide date and details:
Does the client have a history of Peripheral Vascular Disease?
- Yes
- No
If yes, provide details with date(s) and any treatment (e.g. stent, bypass surgery, other)
Does the client have a history of Coronary Artery Disease?
- Yes
- No
If yes, provide details with date(s) and any treatment (e.g. stent, bypass surgery, other)
Does the client have a history of Heart Attack?
- Yes
- No
If yes, provide details with date(s) and any treatment (e.g. stent, bypass surgery, other)
Has the client ever had a stress test?
- Yes
- No
If yes, provide date:
MM slash DD slash YYYY
Test results:
Is there a family history of cardiac or vascular disease?
- Yes
- No
If yes, provide the details of whom, what condition, their age of onset, age at death (if applicable):
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:
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

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

Carotid Artery Stenosis

Carotid Artery Stenosis Questionnaire