* 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 Angioplasty, please answer the following:

1. Please list Date(s) of the Angioplasty (PTCA): 

            How many Vessels?   1 2 3 4 5

2. Has your client had a heart attack?  Unknown Yes No      Bypass surgery?  Unknown Yes No

            Please explain:  

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

            Please explain:  

4. Has a follow up stress test (exercise) EKG been completed

    since the PTCA?   Unknown Yes No

              Normal:       Unknown Yes No     Date:  

              Abnormal:    Unknown Yes No     Date:  

           Please Explain:   

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

            Please explain:  

6.  Has your 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:   

7. Has your client smoked 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 (cancer, etc.)?    Unknown Yes No

            Please explain:  

If possible, please submit a copy of the angiogram report and any recent stress test by fax to