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 Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Any family history of cardiac disease?YesNo 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?YesNoIf yes, grade of murmur (if known):Has the client had valve repair?YesNoIf yes, date of surgery:Has the client had valve replacement?YesNoIf yes, date of surgery; type of valve (mechanical, tissue):Any history of additional surgery/re-operation?YesNoIf yes, provide date/detailsAny post-op insufficiency present?YesNoIf yes, to what degree (mild, moderate, severe):Select all tests that have been done.EKG?YesNoIf yes, provide date and results:Stress test?YesNoIf yes, provide date and results:Echocardiogram?YesNoIf yes, provide date and results:Holter monitor?YesNoIf 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