If your client has Atrial Fibrillation, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Is the atrial fibrillation/flutter
        Chronic (permanent)
        Paroxysmal (intermittent)


   3.  Have any of the following ocurred ?
       Black-Out
       Dizzyness (light-headedness)/Faint Feeling
       Palpitations
       Chest Discomfort


   4.  Have any of the following tests been done ? If so, please provide date and results :
       ECG
          Date   Results 
       Echocardiogram
          Date   Results 
       Stress Test
          Date   Results 
       Holter Monitor
          Date   Results 


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 

   6.  The cause of the atrial fibrillation/flutter is due to :
       Coronary Heart Disease
       Thyroid Disease
       Mitral Valve Disease
       Alcohol
       Unknown or Other
       Cardiomyopathy


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


   8.  Does your client have any major health problems ? Yes   No 

       (example: heart disease, etc.)

       If yes, give details: