If your client has had Chest Pain or Angina, please answer the following ?


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date when first ocurred ? 


   2.  Is your client on any medication ? Yes   No 

       If yes, give details: 

       

   3.  Has your client had any of the following tests ? (check all that apply)
        Resting EKG
        Thallium Stress EKG
        Angiography
        Stress EKG
        Stress Echocardiogram
        Ultrafast CT
        Muga Scan


   4.  Please check if your client had any of the following ? (check all that apply)
        High Blood Pressure
        Diabetes
        Family History of Heart Disease
        Elevated Cholesterol


   5.  Has your client had any of the following ? (check all that apply)

        Heart Attack(s) - Date(s) 


        Bypass Surgery - Date(s)  Number of Vessels 


        Angioplasty(ies) - Date (s)  Number of Vessels 


   6.  Has your client smoked cigarettes in the last 12 months ? Yes   No