Pacemaker

Pacemaker 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
Date of pacemaker implant:
MM slash DD slash YYYY
Reason for the implant:
Have any of the following tests been completed?
- Resting EKG
- Stress EKG
- Thallium Stress EKG
- Echocardiogram
- Holter Monitor
- Chest X-ray
- Other
If Other, please specify.
If applicable, please provide dates for any completed tests listed above.
Has the client been diagnosed as having any of the following:
- Bradycardia
- Cardiomyopathy
- Paroxysmal atrial fibrillation
- Congenital heart block without other heart disorder
- Congenital heart block with other heart disorder
- Chronic atrial fibrillation
- Sick sinus syndrome
- Atrial flutter
- Heart block associated with coronary artery disease
- Heart block - First Degree
- Heart block - Second Degree
- Heart block - Third Degree
- Other
If Other, please specify.
Are there any current symptoms of any heart disease (select all that apply):
- Dizziness or light headedness
- Blackouts
- Chest pain
- Palpitations
- Other
If Other, please specify.

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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