Quote Request. Advisor Information. Client Information. Medical History. Driving History. Advisor Company Date. Phone Fax.
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- Dora Ferguson
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1 Advisor Information Advisor Company Date Phone Fax Client Information Client Name Date of Birth Occupation Plan and amount of insurance requested: Has the case been submitted to other companies in the last 12 months? Yes No If yes, list companies, dates, and action taken: Medical History Height: Weight: Male Female Any weight change (10 pounds or more) in the last year? How much? Reason for change: Any nicotine use within 60 months? Yes If yes, type and date of last use: No Has client seen a doctor within past 3 years? Yes No If yes, when and why? What tests were done? Latest blood pressure reading: EKG Cholesterol/HDL Date: Date: Date: List any medications, including over-the-counter medications and vitamins. Indicate dosage and the reason for taking the medication. Does client have a routine exercise program? Yes No If yes, please describe: Driving History In the past 5 years, has client been convicted of two or more moving violations, driving under the influence of alcohol or other drugs, or had their driver s license suspended, restricted or revoked? Yes No If yes, provide details:
2 Family History Has any family member had cancer, diabetes, high blood pressure, heart disease or kidney disease prior to age 60? Yes No If yes, identify family member, disorder and age at onset: Cardiac Disorder Name and address of cardiologist: Date and reason for last visit: Date of most recent stress test: Date of most recent echocardiogram: Any History of Date of Onset: Treatment Given and Results Angina (chest pain) MI (heart attack) Irregular heart beat Valve Disorder Coronary artery disease Ever had the following Date: Coronary catheterization? Bypass surgery (CABG)? Angioplasty (PTCA)? Valve surgery or replacement? Stent Placement # of Vessels: # of Vessels: Which Valve? Which Arteries? Amount of blockage?
3 Any current symptoms (chest pains, pressure, dizziness, blackouts, shortness of breath, etc.)? If so, how often? What medication is client taking (including over-the-counter, medication and aspirin? Does client carry nitroglycerin? Date of last usage? *Copies of catheterization reports, stress tests, and echocardiograms will assist in evaluation the client s history Asthma/COPD When diagnosed: Medication: # of Attacks per year: Date and severity of last attack: Seasonal? Any hospitalizations? When? Aviation Hours flown as Pilot or Co-Pilot: Purpose (civilian, military): Any Other Avocation Please specify: Cancer Type of Cancer: Location: Staging: Grading, or copy of pathology report: Any positive lymph nodes: Depth or lever: Date of surgery: Any radiation or chemotherapy: If yes, date treatment ended: Any recurrence of cancer: Any other medical problems: Crohns/Colitis When diagnosed: Any surgery? # of attacks per year: Current medication: Date of last episode: Diabetes Date diagnosed: Treatment (oral meds, insulin, diet)? # units of insulin: # of regular doctor visits per year? Any other medical impairments or complications: Latest fasting blood sugar and date: Latest glychemoglobin and date:
4 High Blood Pressure Date of diagnosis: Your average readings: Do you monitor readings at home? Medication: Any other impairments? Lab Abnormalities What tests were abnormal? Any diagnosis given? Results and date: How long has test been abnormal? Psychiatric Diagnosis: Date: Medication: Hospitalization: Suicide attempts? Currently employed? Substance Abuse Date stopped using: Duration used: Kind of substance: Amount used: Type of treatment: Attend AA or other programs? Any relapses? Are liver functions normal? If no, give readings: Any motor vehicle violations or DUIs? Any other medical problems? TIA/CVA Seizures (Transient ischemic attack-ministroke/stroke) Date of episode: # of episodes: Any residuals? Type of treatment or medication: Any Impairment Not Listed Above Diagnosis given and date: Treatment: Medications: Date of last follow-up: Additional Comments
5 Please attach additional page if needed Quote Request
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