Impaired Risk Stroke Questionnaire Agent Information Agent Name Address   Phone Fax E-Mail 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. Date of first stroke mm   yy   2. How many strokes have occurred in the last 24 months? select one None 1 2 or more   3. Has client ever had a carotid artery surgery as a result of a stroke? Yes    No If yes, when     mm   yy 4. Does client have any of the following residual neurological deficits? Slurred speech Loss of use of limb Restricted use of limb Other 5. Date of last stress EKG mm   yy 6. Date and result of last cholesterol reading reading    mm   yy   7. Date and result of last blood pressure reading reading    mm   yy   8. 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   9. Are there any other illnesses/impairments?   10. What medications are currently being taken?    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   Additional Information