Pacemaker 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 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. 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