* 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 a heart attack, please answer the following:

1. Please list the date(s) of the heart attack(s):  

2. Has your client had any of the following?

            Echocardiogram?              Unknown Yes No    Date?  

            Coronary catherization?   Unknown Yes No    Date?  

           Coronary angioplasty?      Unknown Yes No    Date?  

            Bypass Surgery?              Unknown Yes No    Date?  

           Arrhythmia?                       Unknown Yes No    Date? 

            Results of the above if known:  

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

           If yes, please explain?  

4. Has a follow-up stress (exercise) EKG been completed since the

    heart attack?   Unknown Yes - Normal Yes - Abnormal No

5. Has your client had any chest discomfort since the heart attack?    Unknown Yes No

            If yes, please explain?  

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

            Elevated cholesterol?      Overweight? 

            High Blood Pressure?      Diabetes?      

            Family history of heart disease?  

            Please elaborate on any checked items if possible?

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

8. Does your client regularly exercise?   Unknown Yes No

9. Does your client have any other major health problems

    (ex. Cancer, etc)?    Unknown Yes No

           If yes, Please explain: