* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has mitral valve disorders, please answer the following:

1. How long has this abnormality been present? (years)  

2. Have any of the  following occurred?

            Chest   pain?     Unknown Yes No     Trouble  breathing?   Unknown Yes No

            Heart failure?   Unknown Yes No     Palpitations?               Unknown Yes No

            Atrial Fibrillation?   Unknown Yes No

3. Is there a history of any other heart disease in addition to the mitral  valve disorder

    (problems with other valves, coronary artery disease, etc.)?    Unknown Yes No

            If yes, please explain? 

4. Have studies been completed? (Check all that apply)

            Echocardiogram?    Unknown Yes No    Date?  

            Catheterization?      Unknown Yes No    Date?  

            No Studies Done?  

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

           If yes, what medications?  

6. Has your client smoked cigarettes in the past 12  months?    Yes No

7. Does your client exercise regularly?   Unknown Yes No

7. Does your client have any other major health problems

    (example: cancer, etc.)   Unknown Yes No

            If yes, please explain?