If your client has a history of CVA/Stroke, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date(s) of CVA(s) ? 


   2.  Is your client on any medications ? Yes   No 

       If yes, give details:  


   3.  Does your client have any current neurological residuals ? Yes   No 

       If yes, give details:  


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


   5.  Does your client have any of the following conditions ? (select all that apply)
       High Blood Pressure
       High Cholesterol
       Coronary Artery Disease
       Atrial Fibrillation
       Diabetes
       Peripheral Vascular Disease
       Heart Murmur
       Cartoid Disease


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

       (example: cancer, etc.)

       If yes, give details: