Heart Valve 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 Any family history of cardiac disease? Yes No If yes, whom? Age of onset: Current age or age at death: Age/date first diagnosed: Type of disorder: Congenital Valve prolapse Insufficiency Stenosis Other If other, please describe: Which valve(s) are involved? Pulmonic Aortic Mitral Tricuspid Does the client have a Bicuspid aortic valve? Yes No If yes, grade of murmur (if known): Has the client had valve repair? Yes No If yes, date of surgery: Has the client had valve replacement? Yes No If yes, date of surgery; type of valve (mechanical, tissue): Any history of additional surgery/re-operation? Yes No If yes, provide date/details Any post-op insufficiency present? Yes No If yes, to what degree (mild, moderate, severe): Select all tests that have been done.EKG? Yes No If yes, provide date and results: Stress test? Yes No If yes, provide date and results: Echocardiogram? Yes No If yes, provide date and results: Holter monitor? Yes No If yes, provide date and results: Other test? If yes, provide dates and results: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