Stroke (CVA)/Mini Stroke (TIA)

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Stroke (CVA)/Mini Stroke (TIA) 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
Type:
- Stroke
- Mini stroke (TIA)
Date:
Date Format: MM slash DD slash YYYY
What follow-up studies were done following the stroke/mini stroke (select all that apply):
- CT scan
- MRI scan
- Carotid ultrasound
- Echocardiogram
- Other
If Other, please specify.
Has the client been diagnosed with Hypertension?
- Yes
- No
If yes, current reading:
Has the client been diagnosed with elevated cholesterol?
- Yes
- No
If yes, most recent reading:
Has the client had a heart attack (MI)?
- Yes
- No
Date(s):
Has the client been diagnosed with Diabetes?
- Yes
- No
Date of diagnosis:
Treatment:
Most recent A1C result:
Has the client been diagnosed with Coronary Artery Disease?
- Yes
- No
Date of diagnosis:
Details:
Has the client been diagnosed with Peripheral Vascular Disease?
- Yes
- No
Date of diagnosis:
Details:
Has the client been diagnosed with valve disorders?
- Yes
- No
Date of diagnosis:
Details:
Has the client been diagnosed with Cardiomyopathy?
- Yes
- No
Date of diagnosis:
Details:
Has the client been diagnosed with Atrial Fillibration?
- Yes
- No
Date of diagnosis:
Details:
Describe any symptoms experienced at the time of the stroke/mini stroke:
Describe any residual neurologic deficits or other residual effects fro the stroke/mini stroke:
Any changes in ADLs (Activities of Daily Living)?
- Yes
- No
If yes, describe below:
On disability?
- Yes
- No
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:
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

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Stroke (CVA)/Mini Stroke (TIA)

Stroke (CVA)/Mini Stroke (TIA) Questionnaire