Heart Valve Disease

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Heart Valve Disease 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
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: 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
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:
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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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Heart Valve Disease

Heart Valve Disease Questionnaire