* 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 Stroke (TIA/CVA), please answer the following:

1. Please list All the date(s) of the CVA(s) or TIA(s)?  

2. Were any  of the following studies completed?

            Carotid ultrasound?                   Unknown Yes No    Date?  

            Head CT scan or MRI scan?    Unknown Yes No    Date?  

            Echocardiogram?                       Unknown Yes No    Date?  

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

            If yes, please describe:    

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

            Elevated cholesterol?         Diabetes?                 Stroke?      

            High Blood pressure?         Heart Attack?       

            Peripheral vascular disease          Coronary artery disease?    

            Please describe any items checked?  

5. Has your client smoked cigarettes in thee last 12 months?   Yes No

6. Has surgery ever been done on the carotid artery(ies)?   Unknown Yes No

           If yes, please give details?  

7. Please give the date and result of the most recent blood pressure reading:

            Date?         Result? 

8. Is your client fully recovered?   Unknown Yes No

9. Does your client have any other major health problems

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

           If yes, please give details: