If your client has had a stress ECG, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Was the Stress ECG ?
        Normal
        Abnormal
        Borderline


   2.  Was any other testing completed ? (check all that apply)
       Thallium Stress ECG     Normal   Abnormal
       Stress Echocardiogram   Normal   Abnormal
       Coronary Angiogram      Normal   Abnormal


   3.  Has your client had any of the following ? (check all that apply)
       History of Chest Pain
       Elevated Cholesterol
       Diabetes
       Overweight
       High Blood Pressure
       Family History of Heart Disease


   4.  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 


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


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


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

       (example: heart disease, etc.)

       If yes, give details: