If your client is known to have Bundle Branch Block, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Type of BBB present ?
        CLBBB
        LAHB or LPHB
        Bifascicular Block
        CRBBB
        IRBBB

   2.  How long has the abnormality been present ? 

   3.  Has there been any change in the ECG ? Yes   No 

       If yes, give details: 


   4.  Has the client had any of the following ? (check all that apply)
       Chest Pain or Coronary Heart Disease
       Cardiomyopathy
       High Blood Pressure
       Congenital Heart Disease
       Valvular Heart Disease


   5.  What cardiac studies have been completed ?
       Exercise Treadmill or Thallium
          Result?   Normal    Abnormal
       Resting or Excercise Echocardiogram
          Result?   Normal    Abnormal
       Other


   6.  Is your client on any medication ? Yes   No 

       If yes, give details: 

   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: