Stroke (CVA)/Mini Stroke (TIA) 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 Type: Stroke Mini stroke (TIA) Date: 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 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