* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?  

        *Sex?   Male Female

If your client has had an Arrhythmia / Irregular Heart Beat problem, please answer the following:

1. Please list date when first diagnosed: 

2. Is the irregular heart beat due to:

             Premature supraventricular atrial beats?  Unknown Yes No

             Premature ventricular beats?                     Unknown Yes No  

            Chronic atrial flutter or fibrillation?            Unknown Yes No  

            Paroxysmal atrial or fibrillation?                 Unknown Yes No

3. Are any symptoms with the irregular heart beat:

           Black out?      Unknown Yes No      Dizziness?                Unknown Yes No  

           Palpitations?   Unknown Yes No      Chest Discomfort?  Unknown Yes No

4. Have any of the following test been done:

            Stress EKG?          Unknown Yes No  

            Date and results? 

            Echocardiogram?   Unknown Yes No  

            Date and results? 

            Halter Monitor?    Unknown Yes No

            Date and results? 

5. Is your client on Medications?  Unknown Yes No

            Explain Medications? 

6. Please indicate the cause of the irregular heart best if it is due to:

            Heart disease?  Unknown Yes No    Thyroid disease?  Unknown Yes No   

            Alcohol?   Unknown Yes No

7. Has your client smoked cigarettes in the last 12 months?    Yes No  

8. Does your client exercise regularly?   Unknown Yes No

9. Does your client have any other major health problems

    (i.e. Cancer, Stroke,etc.)?   Unknown Yes No

            Please Explain?