Cardiac Disease Questionnaire Please answer all questions applicable to the client's medical history. Karledag. Experience, Rel vosuernane Pert hom Giounner pone (22%) 530-2032 one ea lagl ia T Client Name yo Here Mengna oiteofsith Male Cera Face Amount___ Max Premium $____ OU OWL Diem Dsunivorship Does the cient curently smoke cigarettes ClYes No no, did helshe ever smoke? SZNever C]Quit (date). Does the client currently use any other tobacco products (e.g. nicotine patch, cigars, pipe, snutf, Nicorette gum, etc) Yes BBNo If yes, please provide deta: \When did hershe last use any form of tobacco: (Month) sai) Type ted last_ Date(s) oF frequency of episode(s) of symptoms ‘i chest pain, GHeart attack Provide dates if any of the following tests or revascularization procedures have been done Resting EKG. stress test sues thallium, Bitchocardiogra Distress echo EBT (CT of the heart) Dothec Provide dates and rests of surgical procedures Bypass Di Angioplasty PCA. Di coronary artery stents How many vessels are imwoved =O 12,3 or more Which vessels, Does the cardiologist consider it COM Diooderate — Cisevere ‘What conditions has the client been diagnosed with Diabetes Age of onset___ THigh blood pressure Most recent reading, Decent A1C test results Di itregular heartbeat Clother arterial disease carotid GiPeripherat Vascular Bi cerebrovascular Fer havronce Prolesdonal Ui On — ret fend oui in wight of sales fore pubic Prod {leon weougn Cur ao'el approved" ose Fy en 0731.12 Nitrest any oars goverment agency "hiayloweaue mM Conyignt @ 2012 rams Ute inuronce Series. ‘fe nrince SererCardiac Disease Questionnaire Does the client take any current medications including preventathe aspirin Ves [INO ‘Name of Medication prescription or otherwise) Dates Used | Quantity Taken Frequency Taken Mipco phenolale Zr [a4 [09 Jog ap iia Ab az fo IAs 07/05 [7 ap Biron of 0} 3H Gites a dg Does the client engage in any regular exercise or sporting activity les CN Hf yes, provide details balan euler, LUst any other major health problems the client has e.g. cancer, ec) Heart transplant dete: 01/04/04 adolf yg wcPfiencea ui n mics ciate a he pbs Poaias mapopare Sheed nsagh curs seo ognoied one ata, Ba TE Net SSsoSoy oyteasa govermnan courey “woyloweaue Crump Copyright© 2012 Cramp Lie nnrance Series ne Le insane Sees