* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has a pacemaker, please answer the following:

1. Please list the date when the pacemaker was implanted?  

2. The pacemaker was implanted for:

            Heart block associated with coronary artery disease?    No Unknown Yes

            Congenial heart block with other heart disorder?            No Unknown Yes

            Congenial heart block without other heart disorder?       No Unknown Yes

            Complete heart block or sick sinus syndrome?                No Yes Unknown

            Chronic underlying atrial flutter/fibrillation?                    No Yes Unknown

            If other, please give details?  

3. Have any of the following pacemaker complications occurred?

            Infection?                            No Yes Unknown

            Pacemaker malfunction?    No Yes Unknown

            Blood clots?                         No Yes Unknown

            Perforation?                         No Yes Unknown

            Any other pacemaker  problems, please explain:  

4. Are there any continuing symptoms since the pacemaker was implanted?    Unknown Yes No

            If yes, please give details:   

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

            If yes, please give details:   

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

7. Does your client regularly exercise?   Unknown Yes No

7. Does your client have any other major health problems

    (ex: cancer, etc.)?    Unknown Yes No

            If yes, please give details: