* 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 coronary bypass surgery, please answer the following:

1. Please list the date(s) of the bypass surgery:  

2. How many vessels involved?   1 2 3 4 5

3. Has you client had any of the following:

            Heart Attack?                 Unknown Yes No    If yes, date? 

            Coronary angioplasty?   Unknown Yes No    If yes, date? 

            Heart Failure?                Unknown Yes No    If yes, date?  

            Valve Surgery?              Unknown Yes No    If yes, date?  

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

            If yes, please explain?  

5. Has a follow-up stress (exercise) EKG:   Unknown Yes No  Results if known:   Normal Abnormal Unknown

6. Has your client had any chest discomfort since the bypass surgery?    Unknown Yes No .

            If yes, please explain:   

7. Has you client had any of the following:

            Elevated cholesterol?    Unknown Yes No                         Overweight?    Unknown Yes No

            High Blood Pressure?   Unknown Yes No                         Diabetes?         Unknown Yes No

            Family History of Heart Disease?   Unknown Yes No

            Please explain:  

8. Does your client exercise regularly?   Unknown Yes No

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

10. Does your client have any other major health problems

      (ex. Cancer, etc.)?   Unknown Yes No

            Please explain:  

Please submit a copy of the angiogram report and any recent stress tests if possible?