Impaired Risk
Heart Disorders Questionnaire
Agent Information
Agent
(required)
Address
Phone
(required)
Fax
E-Mail
(required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth
mm
dd
yy
Sex
M
F
Height
Feet
2 '
3 '
4 '
5 '
6 '
7 '
8 '
9 '
Inches
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs.)
Smoker
Yes
No
(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type
Select one
Term
UL
Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied
mm
yy
Company
Declined
Postponed
Rated table
1. Which of the following procedures has the client undergone?
Coronary bypass
mm
yy
age
Angioplasty (go to #4)
mm
yy
age
2. How many grafts were performed?
select one
1
2 or 3
4 or more
3. What type of grafts were performed?
select one
Saphenous vein
Internal mammary artery
Both
4. Where was coronary angioplasty performed?
select one
Single artery
More than one artery
5. What conditions preceded the coronary bypass/angioplasty?
check all that apply
Heart attack
Chest pain
Irregular stress EKG
Extreme fatigue
Other
6. Since the coronary bypass/angioplasty, which of these has client experienced?
Chest pain
Irregular stress EKG
Neither
7. What are the names and addresses of the physicians and hospitials with client's complete medical records?
8. Timing and results of last stress EKG?
select one
Past 12 months
1-2 years
3 years or more
results
9. Date and results of last cholesterol reading.
mm
yy
10. Date and result of last blood pressure reading?
mm
yy
11. Has either parent, or any sibling, died before age 65, other than by accident?
Yes
No (If yes, list relationship(s) and cause)
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
Relationship
father
mother
sister
brother
cause
12. How many times per week does client exercise?
select one
None
1 time per week
2 times per week
3 times per week
4 times per week
5 times per week
6 times per week
7 times per week
More than 7
Type of exercise
13. Are there any other illnesses/impairments?
14. What medications are currently being taken?
Additional Information