Carotid Artery Stenosis 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 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):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