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Heart Attack (Myocardial Infarction) Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1.
LIST DATE (S) OF HEART ATTACK (S) AND SEVERITY OF EACH:
DATE
 
MILD, MODERATE,  SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?

DATE  
MILD, MODERATE,  SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?

DATE  
MILD, MODERATE,  SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?

2. WHAT CONDITION (S) PRECEDED THE HEART ATTACK (S)?
IRREGULAR STRESS EKG
IRREGULAR EKG
CHEST PAIN
ARRHYTHMIA OR IRREGULAR HEART BEATS

3. ACTIVITIES CAPABLE OF PERFORMING (CHECKING LEVEL OF EXERCISE THAT BEST APPLIES):
LEVEL ONE- HEAVY LABOR HANDBALL, CROSS COUNTRY, SKIING, RUNNING 10 MINUTE MILES, BICYCLING AT 12 MPH

LEVEL TWO- SHOVELING, WOOD CUTTING, CANOEING, JOGGING,12 MINUTE MILES, SWIMMING CRAWL STROKE, ROWING MACHINE. 

LEVEL THREE-CARPENTRY, LAWN MOWING, SINGLES TENNIS, DOWNHILL SKIING, SWIMMING BREAST STROKES

LEVEL FOUR- SEDENTARY LIFE STYLE ( UNABLE TO DO ANY OF LEVELS ONE THROUGH TO THREE)

4. DATE LAST CONSULTED PHYSICIAN:
WHAT TREATMENT (S) HAVE BEEN PRESCRIBED? LIST ALL MEDICATIONS

SURGERY? IF YES, DATE:

SURGERY?
IF YES, DATE:

NUMBER OF ARTERIES OR GRAFTS PERFORMED ON: DATE:  
OTHER TREATMENTS:

5. CLIENT'S OCCUPATION

6. SINCE THE HEART ATTACK, HAS THE CLIENT EXPERIENCED ANY OF THE FOLLOWING?
CHEST PAINS OR ANGINA 
IRREGULAR EKG OR STRESS EKG 
ARRHYTHMIA 
CONGESTIVE HEART FAILURE

7. WHAT TESTS HAVE BEEN PERFORMED? (CHECK ALL THAT APPLY)
RESTING EKG, DATE: RESULTS

EXERCISE EKG, DATE: RESULTS

THALLIUM TEST, DATE: RESULTS

STRESS ECHO, DATE: RESULTS

CORONARY CATCH, 
DATE:
RESULTS

8. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO

9. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC DIASTOLIC

10. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL

12. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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