* 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 Artery Disease, please answer the following:

1. Was the stress EKG:   Unknown Normal Abnormal Borderline

2. Was other testing completed:  

            Thallium EKG?                  Unknown Yes No    Findings?   Unknown Normal Abnormal

            Stress echocardiogram?    Unknown Yes No    Findings?   Unknown Normal Abnormal

            Coronary angiogram?        Unknown Yes No    Findings?   Unknown Normal Abnormal

            Please explain any abnormal findings:     

3. Please check if your client has had any of the following:

            History of chest pain?      Unknown Yes No      Elevated cholesterol?    Unknown Yes No

            Overweight?                     Unknown Yes No      Diabetes?                       Unknown Yes No

            High blood pressure?       Unknown Yes No

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

           If yes, please explain:   

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

6. Has your client had any of the following:

            Heart attack?                 Unknown Yes No     Dates?  

            Bypass surgery(ies)?     Unknown Yes No # of Vessels? None 1 2 3 4 5 6  Dates?  

            Angioplasty(ies)             Unknown Yes No # of Vessels? None 1 2 3 4 5 6 Dates?  

            Chest pain or angina?    Unknown Yes No    Heart Murmur?   Unknown Yes No

            Abnormal heart rhythm or pulse?   Unknown Yes No

7. Does your client exercise regularly?   Unknown Yes No

8. Does your clients family have a history of heart disease?   Unknown Yes No

            If yes, please explain:  

9. Does your client have any other major health problems

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

            Please explain?