* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

        *Sex?   Male Female

If your client has an aortic valve disorder, please answer the following:

1. How long has this abnormality been present?     Years

2. Please check if your client has any of the following?

                    Chest Pain?                Unknown Yes No            Palpitations?    Unknown Yes No         

                    Trouble Breathing?   Unknown Yes No            Dizziness?         Unknown Yes No              

                    Heart Failure?           Unknown Yes No          

3. Is there a history of any other heart disease in addition to the aortic valve disorder

    (problems with other valves, coronary artery disease, etc.?    Unknown Yes No

        If yes, please give details:  

4. Have Additional studies been completed?   Unknown Yes No   

        If yes, please give details: 

5. Is your client on any medications?   Unknown Yes No

        If yes, please give details: 

6. Has your client smoked cigarettes in the past 12 months?   Yes No

7. Does your client exercise regularly?   Unknown Yes No

8. Does your client have any other major health problems

    (example cancer, etc.)?   Unknown Yes No

       If yes, please describe: